|Year : 2022 | Volume
| Issue : 3 | Page : 267-270
Influence of nonsurgical periodontal therapy on serum hemoglobin levels among patients with type 2 diabetes mellitus: A cross-sectional study
Jatinder Singh1, Inderpreet Kaur2, Gurpreet Inder Singh3, RG Saini4, Hemant Kumar Gupta5, Rakendra Singh6
1 Department of Public Health Dentistry, Adesh Institute of Dental Sciences and Research, Bathinda, Punjab, India
2 Department of Prosthodontics, Adesh Institute of Dental Sciences and Research, Bathinda, Punjab, India
3 Department of Community Medicine, Adesh Institute of Dental Sciences and Research, Bathinda, Punjab, India
4 Centre of Interdisciplinary Biomedical Research, Adesh University, Bathinda, Punjab, India
5 Department of Periodontics, Adesh Institute of Dental Sciences and Research, Bathinda, Punjab, India
6 Department of Medicine, Adesh Institute of Dental Sciences and Research, Bathinda, Punjab, India
|Date of Submission||28-Jun-2021|
|Date of Decision||05-Apr-2022|
|Date of Acceptance||09-Jun-2022|
|Date of Web Publication||12-Sep-2022|
Department of Public Health Dentistry, Adesh Institute of Dental Sciences and Research, Barnala Road, Bathinda - 151001, Punjab
Source of Support: None, Conflict of Interest: None
Aim: The present study was carried out to examine the association between periodontitis and glycated hemoglobin (HbA1c) in Type 2 diabetes mellitus adults. The objective of the study was to assess the effect of nonsurgical periodontal therapy on serum levels of HbA1c in patients with Type 2 diabetes mellitus and moderate-to-severe periodontitis. Material and Methods: The study population consisted of 78 Type 2 diabetes mellitus patients aged 30–70 years suffering from chronic generalized periodontitis. The patients were selected randomly from among the patients reporting at medicine outpatient department from July 2018 to August 2019. They were assessed for the presence or absence of gingival bleeding, presence or absence of periodontal pockets, and loss of attachment using the Community Periodontal Index (World Health Organization, 2013). Data were analyzed using the statistical package SPSS (version 21.0) and paired t-test at P < 0.05. Results: The mean reduction in haemoglobin levels of patients with moderate to severe periodontitis were significantly reduced by 1.19 in Group I, 0.51 in Group II, and 0.09 in Group III respectively after 3 months of nonsurgical periodontal therapy. This periodontal therapy was clinically effective and had a significant effect on the participant's glycemic control. Conclusion: This periodontal therapy was clinically effective and had a significant effect on the participant's glycemic control.
Keywords: Diabetes mellitus, gingival bleeding, periodontal pocket, periodontal therapy
|How to cite this article:|
Singh J, Kaur I, Singh GI, Saini R G, Gupta HK, Singh R. Influence of nonsurgical periodontal therapy on serum hemoglobin levels among patients with type 2 diabetes mellitus: A cross-sectional study. J Indian Assoc Public Health Dent 2022;20:267-70
|How to cite this URL:|
Singh J, Kaur I, Singh GI, Saini R G, Gupta HK, Singh R. Influence of nonsurgical periodontal therapy on serum hemoglobin levels among patients with type 2 diabetes mellitus: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2022 Sep 25];20:267-70. Available from: https://www.jiaphd.org/text.asp?2022/20/3/267/355884
| Introduction|| |
The Type 2 diabetes mellitus is regarded nowadays as a worldwide epidemic. According to the World Health Organization (WHO), the global estimated number of people with Type 2 diabetes mellitus will reach 366 million in 2030. Severe periodontal disease (PD) often coexists with severe diabetes mellitus. Epidemiologic studies have found that patients with diabetes, especially when inadequately controlled, are at an increased risk of developing PD, exhibit more severe and more extensive destruction of periodontal supporting tissues (deeper pocket depths and more clinical attachment loss [AL]),, and show accelerated alveolar bone loss. On the other hand, the presence of PD itself in diabetic patients may influence their glycemic control. The association between diabetes and PD is well documented.
Infections of the periodontal origin are mostly chronic and Gram-negative. They are not only restricted or confined to the tissue surrounding the tooth, but have rather potential systemic effects. These systemic effects in most individuals in a susceptible host could adversely affect the existing systemic condition. Severe periodontal infections and inflammation may, thus, be an important risk factor in the progression of diabetes.
It has been observed that there is a two-way relationship between diabetes mellitus and PD/infection. The periodontal infection and advanced glycation end products-mediated cytokine upregulation increases the tissue destruction and complicates the severity of diabetes and degree of metabolic control. It has been proposed that elimination of periodontal infection and reduction of periodontal inflammation may lead to a significant reduction in insulin requirement in diabetes patients.
The glucose assay developed to diagnose diabetes mellitus called glycated hemoglobin (HbA1c) assay is a quick and accurate method to determine patient's level of diabetic control. Elimination of infection and associated inflammation and pharmacological intervention to inhibit the glycosylation results in the significant short-term improvement in the concentration of HbA1c.
There is, however, limited information regarding the effect of treatment of PD on metabolic control of diabetes mellitus. Therefore, in view of the observations given above, the present study was planned with the following objective: To assess the role of nonsurgical periodontal therapy on serum levels of HbA1c in patients with Type 2 diabetes mellitus in moderate-to-severe PD.
| Materials and Methods|| |
The study was conducted on 78 (sample size obtained using the Open Epi, www.openepi.com, version 3 (http://openepi.com/samplesize/htm) with comparing the two means) Type 2 diabetes mellitus patients suffering from chronic generalized periodontitis selected from among the patients reporting at the department of periodontics and referral from the diabetes unit of the medicine department. The subjects in the age group of 30–70 years were selected randomly without discrimination of sex, caste, religion, and socioeconomic status. Detailed medical and dental histories of the subjects were recorded. The subjects were explained the purpose of the study and the procedures involved. Serum HbA1c was measured with the help of fully automated Biorad D-10 DJ analyzer. This hemoglobin testing system uses the principle of high-performance liquid chromatography. In this, a dual piston, low pulsation pump and a proportioning valve delivers the buffer solution to the analytical cartridge and detector. The software performs a reduction of raw data collected from each analysis that may include use of a calibration factor. The precision (% coefficient of variation) of the machine used for this purpose is 1.2 and accuracy of the machine mentioned with slope is 1.0663.
The following inclusion criteria were used for recruitment of subjects for the present study:
- Patients suffering from Type 2 diabetes mellitus (whose diagnosis was established and were on regular follow-ups for a minimum of 6 months) having moderate-to-severe periodontitis
- Patients with the presence of at least 15 natural teeth having 5 or more pockets of 5 mm or more and probing AL of 4 mm or more in at least 2 different quadrants which bled on probing and who did not receive any periodontal treatment in the past 6 months
- Patients not having antibiotic therapy in the past 3 months
- Only the patients having physical and mental ability to control their plaque to a clinical and acceptable level were included in the study.
Patients suffering from Type I diabetes mellitus having complications such as retinopathy, nephropathy, and neuropathy with a history of stroke or an acute cardiovascular event over the previous 12 months were not included.
Patients who had their diabetic medication changed during the course of study or in the previous 6 months and those having severe dental infections requiring drainage, antibiotics, extractions, or endodontic therapy were not considered for the study.
Pregnant women and persons on dialysis were also not considered for the study.
The periodontal status was assessed using the gingival bleeding and periodontal pockets. For this purpose, modified Community Periodontal Index (CPI) (WHO, 2013) was used with community index of periodontal treatment needs probe. All teeth present in mouth were examined for the absence or presence of gingival bleeding and the absence or presence of periodontal pockets along with AL.
On the first visit, the periodontal status of the patient was assessed clinically by recording the clinical probing depth (PD) by the single examiner using the modified CPI, 2013, and blood samples were taken to evaluate the serum HbA1c. The patient was recalled after 2 weeks, if the patient had moderate-to-severe periodontitis and HbA1c value was equal to or <7 and >9. The study was conducted from July 1, 2018, to August 31, 2019.
All the patients with Type 2 diabetes mellitus and chronic generalized (moderate to severe) PD were given the option of the treatments being rendered based on their periodontal status and the pocket depth. The patients were divided into three groups, i.e., treatment Group I, treatment Group II, and treatment Group III:
- Treatment Group I (curettage group): This group consisted of patients with pocket depth of 6 mm or more and received full mouth debridement consisting of oral hygiene instructions + subgingival scaling and root planing using ultrasonic device and Gracey curettes under local anesthesia done in 2 visits at 1 week interval (severe periodontitis)
- Treatment Group II (scaling group): This group consisted of patients with pocket depth of 4–5 mm and underwent oral hygiene instructions + supragingival removal of plaque and calculus with ultrasonic scaler. This treatment was given to patients with pocket depth of 4–5 mm (moderate periodontitis)
- Treatment Group III: No treatment group or control group.
The treatment was delivered to all the subjects in Group I and Group II by a periodontist. Chlorhexidine mouthwash rinses were prescribed twice daily for 5 days to patients in all the three groups.
Twelve weeks after the scaling and root planing or only scaling or no treatment, patients were recalled for recording the periodontal status using the CPI modified Index (2013) and blood samples were again taken to evaluate the serum HbA1c.
Informed consent was obtained from the patients before conducting the examination. Approval for carrying out the study was taken from the Institutional Research and Ethical Committees (Ref no-AU/EC/FM/37/2018) dated March 16, 2018. The means and standard deviations (SDs) of the groups were used for statistical analysis. Difference between the two groups was determined using Student's t-test for quantitative variables and Chi-square test for comparison of qualitative variables. The data collected was entered into Microsoft Word Excel sheet 2007 version and subjected to analysis using statistical package of social sciences (SPSS) version 21. Moreover, paired t-test was used with P < 0.05 as level of significance.
| Results|| |
Distribution of the study subjects and their demographic profile is given in [Table 1]. The study population of 78 subjects consisted of 32 males and 18 females among the cases. The control group consisted of 18 males and 10 females. The mean age among the cases (n = 50) and controls (n = 28) was 56.91 years with SD of 13.79 and 58.62 years with SD of 15.38, respectively. The average body mass index among the cases and controls was 24.98 kg/m2 with 4.71 as SD and 24.07 kg/m2 with 5.28 as SD, respectively. Subjects with Type 2 diabetes for >5 years were 35 (44.9%), 15 (19.2%) subjects had Type 2 diabetes for more than 5 years but >10 years, and 28 (35.9%) subjects had Type 2 diabetes since more than 10 years. Of the total subjects examined in this study, 17 (21.8%) had undergone deep curettage (Group I), 33 (42.3%) had undergone only scaling (Group II), and 28 (35.9%) did not under go any treatment and were included in the study as controls (Group III).
The mean pretreatment HbA1c score was 8.02 with a SD of 1.34, whereas the posttreatment HbA1c mean score was 7.17 with SD of 2.04. This was seen to be statistically significant using paired t-test (P < 0.05 as level of significance). However, in the control group, the mean HbA1c score was 8.07 with SD of 1.18 in the pretreatment group and the mean HbA1c in posttreatment group was 7.98 with a SD of 1.48 [Table 2].
|Table 2: Pre- and posttreatment glycated hemoglobin status of patients and controls|
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When the individual groups of treatments being rendered were compared with respect to mean HbA1c, the Group I with deep curettage had the mean HbA1c of 8.05 with 1.86 of SD before treatment and 6.86 with 1.35 as SD after treatment. The reduction in mean HbA1c seen was 1.19 in Group I. When Group II with only scaling was seen, the mean HbA1c before treatment was 7.99 with SD of 1.71, and posttreatment it was 7.48 with SD of 1.14. The mean reduction in HbA1c seen was 0.51. When the Group III with no treatment given was seen, the mean HbA1c reduction seen was 0.09 [Table 3]. This was seen to be statistically significant (P < 0.05 as level of significance).
|Table 3: Comparison of glycated hemoglobin with treatment Group I (deep curettage) and treatment Group II (scaling only) and treatment Group III (no treatment)|
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| Discussion|| |
Reduction in HbA1c is an established outcome measure of diabetes treatment and is related to reduction in hyperglycemia as well as reduction in the risk of a number of complications of diabetes, including retinopathy, kidney disease, and death. A reduction of 0.4% in HbA1c is comparable with that achieved by adding a second antiglycemic medication to the management of hyperglycemia in a patient with diabetes and hence is clinically significant. Change in glycemic parameters in response to periodontal treatment demonstrates that the infection and inflammation associated with PD significantly contributes to the inflammatory burden and negatively impacts the efficiency of pharmacological control of Type 2 diabetes. Further, the reduction of this inflammation by rigorous periodontal treatment can result in better glycemic control.
Casanova et al. reported that nonsurgical periodontal therapy is associated with reduction in HbA1c of the order of 0.4%. Such an improvement in HbA1c may appear to be relatively modest. It may, in fact, have very significant clinical impacts because every 1% reduction in HbA1c is associated with a measurably reduced risk for diabetic complications.
In a study by Chen et al., 2012 (Guangzhou, China), HbA1c as well as all periodontal parameters measured (bleeding on probing, PD and AL) showed improvement after 3 months by nonsurgical periodontal therapy in the treatment group of scaling and root planning compared to minimal treatment group of only scaling. The percentage of sites with PD of 4–5 mm and >6 mm decreased significantly in both the treatment groups, whereas it did not change significantly in the control group. In our study, we saw the similar findings.
In a study by Moeintaghavi et al., 2012 (Dental Research Centre, Mashhad, Iran), periodontal therapy significantly improved all periodontal parameters in the treated group and the mean reduction in HbA1c noted was 0.74% in the treatment group and was significant. In the control group, the mean reduction in HbA1c values was not significant after 3 months. Comparatively, in our study, the mean HbA1c reduction noted was 0.85% within the treatment groups.
In our study it was observed that the mean reduction in HbA1c in the treatment Group 1 and group 2 was 1.19 and 0.51 respectively as compared to 0.74 and 0.66 of treatment group 1 and 2 respectively as in the study of Koromantzos et al. in 2012 (Athens, Greece). The control group in our study showed a reduction of 0.09% in HbA1c.
In a study done by Grossi and Genco 1998 (Buffalo School of Dental Medicine, USA), the reduction in haemoglobin level was 10% when ultrasonic scaling and curettage was combined with doxycycline, 100mg for two weeks after 3 months.
| Conclusion|| |
The nonsurgical periodontal therapy was clinically effective and had a statistically significant effect on the participant's glycemic control. Considering the high prevalence of both these diseases in India, a substantial volume of data needs to be generated through research between the medical and dental fraternities to enable management of these conditions in India.
Implication for clinical practice and public health arising from this study:
- Clinicians should be aware of the “two way street of disease” that results in greater PD in those with diabetes and poorer glycemic control in those with diabetes and periodontitis. Health-care providers should inform patients of diabetes of this link and engage in oral health education programs
- Oral health-care providers should perform a periodontal examination in each newly diagnosed case of diabetes
- Physicians should seek evidence for the presence of periodontitis in patients with diabetes and ask about signs and symptoms (bleeding gums, drifting dentition, halitosis, and gum soreness), and in case of positive history, a referral to an oral health-care provider should be encouraged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Li Q, Hao S, Fang J, Xie J, Kong XH, Yang JX. Effect of non-surgical periodontal treatment on glycemic control of patients with diabetes: A meta-analysis of randomized controlled trials. Trials 2015;16:291.
Carranza FA Jr., editor. Glickman's Clinical Periodontology. 7th
ed. Philadelphia: WB Saunders and CO.; 1990.
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.
Mealey BL, Oates TW. Dibetes mellitus and periodontal diseases. J Periodontol 2006;77:1289-303.
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M, Knowler WC, et al.
Non-insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years. J Periodontol 1998;69:76-83.
Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: A two-way relationship. Ann Periodontol 1998;3:51-61.
Miller LS, Manwell MA, Newbold D, Reding ME, Rasheed A, Blodgett J, et al.
The relationship between reduction in periodontal inflammation and diabetes control: A report of 9 cases. J Periodontol 1992;63:843-8.
Piché JE, Swan RH, Hallmon WW. The glycosylated hemoglobin assay for diabetes: Its value to the periodontist. Two case reports. J Periodontol 1989;60:640-2.
World Health Organisation. Oral Health Surveys – Basic Methods. 5th
ed. France: World Health Organisation; 2013.
Genco RJ, Graziani F, Hasturk H. Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus. Periodontol 2000 2020;83:59-65.
Casanova L, Hughes FJ, Preshaw PM. Diabetes and periodontal disease: A two-way relationship. Br Dent J 2014;217:433-7.
Chen L, Luo G, Xuan D, Wei B, Liu F, Li J, et al
. Effects of non-surgical periodontal treatment on clinical response, serum inflammatory parameters, and metabolic control in patients with type 2 diabetes: A randomized study. J Periodontol 2012;83:435-43.
Moeintaghavi A, Arab HR, Bozorgnia Y, Kianoush K, Alizadeh M. Non surgical periodontal theraoy affects metabolic control in diabetes: A randomized controlled clinical trial. Aust Dent J 2012;57:31-7.
Koromantzos PA, Makrilakis K, Dereka X, Offenbacher S, Katsilambros N, Loannis A, et al
. Effect of non-surgical periodontal therapy on C reactive protein, oxidative stress, and matrix metalloproteinase (MMP) -9 and MMP2 levels in patients with type 2 diabetes. A randomized controlled study. J Periodontol 2012;83:3-10.
[Table 1], [Table 2], [Table 3]