Effect of Conventional Periodontal Treatment (Scaling and Root Planing) on Type-2 Diabetic Patient with Moderate Generalized Chronic Periodontitis: A Clinical Study.

BACKGROUND: The aim is to assess the effect of periodontal therapy and scaling and root planing (SRP) on the metabolic control in Type 2 diabetes mellitus (DM) patients with chronic periodontitis based on the estimation of glycated hemoglobin (HbA1c).
MATERIALS AND METHODS: A prospective, comparative, clinical study was performed on 50 patients suffering from Type 2 DM with moderate, generalized chronic periodontitis. Type 2 moderately controlled diabetic patients with HbA1c values within the range of 6%-8% were selected. The parameters recorded were gingival index, plaque index, sulcus bleeding index, probing pocket depth, clinical attachment level, and HbA1c. The recordings were done at baseline and 6 months after SRP procedures.
RESULTS: Reductions in all the clinical parameters were observed and were found to be statistically significant (P < 0.05).
CONCLUSION: SRP resulted in a statistically significant reduction in the clinical parameters and HbA1c. Hence, periodontal treatment should be included in the management of diabetic patients. Copyright:

INTRODUCTION

Periodontal disease is the periodontal inflammatory process, in which the primary etiologic factor may be microbiologic, systemic, or physical injury. It is a condition that affects and destroys the attachment apparatus. The sign and symptoms are gingival bleeding, increase in probing depth (PD), pain, destruction of periodontal attachment, and tooth loss.[12]

Periodontal disease is best considered as the outcome of an on-going host-parasite interaction between pathogenic microorganism that colonized in the periodontal pocket and host tissues that resist such bacteria or their products.[3] Many systemic diseases and disorders have been impacted as risk indicators or risk factors in periodontal disease. One such example is diabetes mellitus (DM).[4]

DM is a disorder where the body does not produce insulin or does not use it leading in increase sugar levels, resulting in various dangerous complications.[5]

Diabetes is classified in several ways. The new classification system identified four types of DM: Type-1, type-2, “other specific types” and gestational diabetes. Each of the type of DM present with hyperglycemia and insulin requirements or the oral hyperglycemic agent.[6]

DM is complex and globally evolving chronic health problem faced by the world today. The Indian task force on diabetes care has reported that a crude prevalence rate of 9% in urban and 3% in the rural population. The studies reported that at least two-fold increase in the risk of periodontal disease in diabetic when compared with healthy controls.[789] The systemic manifestation of diabetes include atherosclerosis, microangiopathy, ocular retinopathy, and atherosclerotic heart disease. The periodontal manifestations of maternal diabetes are: frequently multiple abscess formation, gingival edema, sessile or pedunculated gingival polyps, loosened teeth, etc. The extensive studies point to the fact that there is no consistent pattern of periodontal disease in people with diabetes.[10]

Infection of periodontal origin are chronic, associated with Gram-negative organisms, not only affecting the tissue surrounding the tooth but also constituting the systemic challenge to immunocompetent cells and cells active in the inflammatory cascade.[11]

The glycosylated hemoglobin assay, a relatively new test used in the diagnosis and monitoring of diabetic patients (American Diabetes Association, 1998),[12] is based on the knowledge that blood glucose becomes irreversibly bound to the hemoglobin molecules. Most importantly, it gives an indication of blood glucose level over an extended period (30–90 days), whereas traditional assay only indicates the glucose level at one point in time. In addition, there is no requirement of fasting before testing.[1314] The normal range of glycated hemoglobin (HbA1c) is 4.5%–6%. The HbA1c value in moderately controlled diabetic is 6%–8%.

The purpose of the study is to evaluate the effect of periodontal therapy on Type-2 diabetic mellitus patients with chronic periodontitis by measuring the level of the HbA1c.

MATERIALS AND METHODS

Thirty subjects with Type 2 DM with moderate generalized chronic periodontitis were recruited for the study from the outpatient department of the Periodontics, Awadh Dental College and Hospital, Jamshedpur, Jharkhand. The study protocol was explained to each potential subject, and written informed consent was obtained before the start of any treatment.

The aims and objectives of the study, along with the duration and method, were elaborated and explained to the subjects. Each patient was divided into two groups as under as treatment and nontreatment (control) groups.

The patients were examined at baseline and after 3 months of periodontal therapy. The participants were instructed to continue with their medical management of DM (oral hypoglycemic agents, diet, and lifestyle) without any modifications during the study period.

Data collection

Clinical periodontal examination: the periodontal parameters were recorded at baseline (day 0) and 3 months following the periodontal treatment.

The parameters recorded were:

Metabolic assessment

For the metabolic assessment, 3–4 mL of venous blood samples were taken from each patient and analyzed for fasting blood glucose, postprandial blood glucose, and glycosylated hemoglobin.

Treatment Regimen

Conventional periodontal treatment includes scaling and root planning under local anesthesia (if necessary) in four sessions. The maximum time interval between each session of scaling and root planning should be 4 weeks.

Follow-up examination done at 3 months including all elements of initial examination (determination of HbA1c and fasting blood plasma glucose, periodontal examination by clinical variable assessment with Plaque Index [PI], Gingival Index [GI] [sillness and loe], sulcus bleeding index [SBI], PD, clinical attachment level).

Posttreatment care

Patients were instructed to maintain proper oral hygiene at least for 1 week after scaling and root planning, followed by brushing using the Charters technique and use chlorhexidine 0.2% mouthwash twice daily.

Recall

Clinical measurements

T0 = At baseline (T0), an expert periodontal examiner measured the following parameters at the experimental sites:

Probing pocket depth (PPD) using a University of North Carolina-15 probe

GI (Loe H and Silness J 1963)

PI (Silness L and Loe H 1964)

SBI (Muhlemann HR and Son S 1971).

T3 = At 3 months after completing nonsurgical periodontal therapy, all parameters were recorded.

The control group received no periodontal treatment during the study period. After completion of the study, these patients were given a full nonsurgical and supportive periodontal treatment if needed.

All the descriptive data for each of the groups, which included mean, standard deviation, were determined. The data derived for each of the groups was analyzed by independent sample Student's t-test. For all tests, a P < 0.05 (5%) was considered statistically significant.

RESULTS

This study was being conducted on 30 patients. Fifteen diabetics and 15 nondiabetics with chronic generalized periodontitis were enrolled.

Out of 15 diabetic subjects, males were 6 (40%) and females were 9 (60%). The mean age in people with diabetes was 50.46 years. In nondiabetic subjects, 9 (60%) were male and 6 (40%) were female, with a mean age of 40.73 years.

The mean values and SD, of all the parameters (PI, BI, GI, PPD, fasting blood sugar [FBS], and HbA1c) were estimated at baseline, 3 months, and 6 months. Multi variant analysis of variance was used to compare the following variables between groups and function of time: HbA1c in blood, glucose in blood, PI, bleeding index, GI, and periodontal PD.

Periodontal parameters

Plaque index

The mean reduction in the PI was it was statistically significant (P < 0.05) at all intervals [Table 1].

Table 1

Differences in clinical and metabolic parameters in diabetic group after conventional periodontal treatment

Clinical parameters
Parameter	Reduction from baseline to 3 months (n=15)		Reduction from 3 months to 6 months (n=15)		Reduction from baseline to 6 months (n=15)
	Mean±SD	P	Mean±SD	P	Mean±SD	P
PI	56.06±3.98	0.00*	−27.66±0.09	0.00*	28.40±3.87	0.00*
BI	32.17±1.26	0.00*	−0.92±2.45	0.98	31.25±1.19	0.00*
GI	0.75±0.31	0.00*	−0.16±0.01	0.89	0.58±0.32	0.00*
PD	0.43±0.26	0.05*	0.05±0.04	0.95	0.49±0.18	0.03*
Metabolic parameters
Parameter	From baseline to 3 months (n=15)		From 3 months to 6 months (n=15)		From baseline to 6 months (n=15)
	Mean±SD	P	Mean±SD	P	Mean±SD	P
FBS	19.01±9.61	0.10	14.11±6.83	0.27	33.14±16.54	0.00*
HbA1c	0.98±0.19	0.04*	0.47±0.30	0.60	1.47±0.49	0.01*

*Significant, P<0.05. FBS: Fasting blood sugar, PD: Probing depth, GI: Gingival index, BI: Bleeding index, PI: Plaque index, SD: Standard deviation

Bleeding index

Mean reduction in BI at baseline to 3 months and baseline to 6 months after periodontal therapy was statistically significant (P < 0.05) in both groups [Table 1].

Gingival index

Reduction in the GI was statistically significant (P < 0.05) in both groups at baseline to 3 months and baseline to 6 months [Tables 1 and 2].

Table 2

Differences in clinical and metabolic parameters in nondiabetic group after conventional periodontal treatment

Clinical parameters
Parameter	Reduction from baseline to 3 months (n=15)		Reduction from 3 months to 6 months (n=15)		Reduction from baseline to 6 months (n=15)
	Mean±SD	P	Mean±SD	P	Mean±SD	P
PI	59.86±0.91	0.00*	−33.06±7.53	0.00*	22.80±6.63	0.00*
BI	36.15±3.31	0.00*	−6.76±1.41	0.22	29.41±4.72	0.00*
GI	0.71±0.11	0.00*	−0.04±0.05	0.89	0.66±0.16	0.00*
PD	0.63±0.23	0.00*	0.38±0.04	0.11	1.01±0.19	0.00*
Metabolic parameters
Parameter	From baseline to 3 months (n=15)		From 3 months to 6 months (n=15)		From baseline to 6 months (n=15)
	Mean±SD	P	Mean±SD	P	Mean±SD	P
FBS	4.80±2.76	0.33	0.62±0.93	0.98	5.42±3.71	0.25
HbA1c	0.11±0.08	0.71	−0.04±0.02	0.94	0.06±0.06	0.88

*Significant, P<0.05. FBS: Fasting blood sugar, PD: Probing depth, GI: Gingival index, BI: Bleeding index, PI: Plaque index, SD: Standard deviation

Probing pocket depth

Reduction in the PD was statistically significant (P < 0.05) in both groups at baseline to 3 months and baseline to 6 months, whereas the mean reduction in both the groups at 3 months–6 months of the interval was not statistically significant (P > 0.05) [Tables 1 and 2].

Metabolic parameter

Fasting blood sugar level

Mean reduction of FBS was statistically significant (P < 0.05) in baseline to 3 months and baseline to 6 months of interval.

Glycated hemoglobin

The mean reduction in HbA1cvalues from baseline to 3 months and baseline to 6 months after the periodontal therapy which was statistically significant (P < 0.05), while HbA1c reduce between 3 months and 6 months of interval, but it was not statistically significant (P < 0.05).

DISCUSSION

The metabolic assessment was based on the assessment of blood HbA1c levels. Blood glucose measurements show the level of glucose in blood at a given moment of time. In contrast, HbA1c measurements predict the level of glucose in blood over a period of time (30–90 days). The glycosylated hemoglobin assay is a relatively new test used in the diagnosis and monitoring of diabetic patient.[141516]

The influence of diabetes on periodontal health and vice versa has been discussed widely in the dental literature.[171819] More direct evidence regarding the effects of periodontal infection on glycemic control in diabetes comes from treatment studies. There is evidence to support periodontal infection having an adverse effect on glycemic control.[202122]

Number of studies reported a high incidence and severity of periodontal disease in diabetic patients as compared with the nondiabetic controls.[1718] After treatment, there were improvements in all of the monitored clinical parameters. The findings of the present study are in support of the above studies.

Significant improvement were seen in plaque control throughout the study which was in agreement with various studies.[1920212223] In the present study, diabetic group plaque score reduction from baseline to 3 months, from 3 to 6 months, and from baseline to 6 months, suggestive of highly significant improvement. In nondiabetic group, plaque score reduction from at all examinations P < 0.00 suggestive of the highly significant improvement in nondiabetic group also Debora et al.[24] show the effect of nonsurgical periodontal therapy on glycemic control in patients with Type 2 DM.

In the present study, clinical parameters evaluated were significantly improved in correlation with plaque control, which might have been due to good patient maintenance and compliance.

Significant changes (P < 0.05) in bleeding index and GI were also evident in the study in both the group. Other studies by Patricia AA et al.,[12] Ricardo FA et al.,[22] Kiran et al.,[25] also showed similar results. PI reductions were 30%–34%, GI reductions were 19%–25%, and the reductions in bleeding on probing were 63%–65% and 60% in diabetics in the studies done by Debora et al.,[24] Kiran et al.[25]

Statistically significant differences (P < 0.05) in mean PD, were found between the two groups (Diabetic and control groups), with better outcomes for the control group. However, both groups showed significant improvements (P < 0.05) at baseline to 3 months and baseline to 6 months.

In the present study, at baseline FBS in diabetic level is 159.53 ± 32.53 mg/ml, at 3 months follow-up, it is 140.50 ± 22.83 mg/ml and at 6 months follow-up, it is 126.39 ± 16.04 mg/ml. The change in FBS from baseline to 3 months is 19.01 ± 9.61 mg/ml (P < 0.05), 3 months–6 months is 14.11 ± 6.83 mg/ml (P > 0.05), and baseline to 6 months is 33.13 ± 16.52 mg/ml (P < 0.05) which shows readings of FBS could not reach up to statistically significant improvement at every examination. FBS is highly variable with transient fluctuation in blood glucose level at the time of sampling.

In this study, lowering in HbA1c level in diabetic group was from baseline to 3 months 12%, from 3 to 6 months 6.5% and from baseline to 6 months 18.3%. It suggests that nonsurgical periodontal therapy leads to lowering in HbA1c levels, especially in patients with an increased DM and periodontal disease. Thus, treatment of chronic periodontitis improves the sugar level status of the diabetic. Moreover, this status is measured by HbaA1c levels, which is an accurate, specific (specificity of HbA1c assay is 83%–89%) and sensitive (sensitivity of HbA1c assay is 45%–90%) marker of long-term metabolic control (30–60 days) in the diabetic population. Reduction in HbA1c level of this findings confirms the results of prior studies as described follow: In the study of Debora RC et al.,[24] and Westfelt E et al.26 both groups showed reductions in HbA1c levels. The change in HbA1c levels was 4% in G1 and 11% in G2 (one-stage full mouth scaling and root planning alone), with a statistically significant difference between groups by ANOVA. Stewart et al. (2001)[9] in a retrospective study, evaluated patients who received scaling and root planning without antibiotics; after 10 months, HbA1c examinations were performed and revealed an average reduction of 17% from baseline HbA1c levels. HbA1c level in nondiabetic control group showed reduction.

CONCLUSION

There is a two-way relationship between DM and periodontitis, with the former producing a greater severity of periodontal disease and the latter compromising blood glucose control in diabetic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.