A Clinical Study to Assess the Severity of Periodontal Disease in Relation to Glycemic Status of Type II Diabetic Individuals.

Background: The study is done to find out the association between the glycemic status of Type II diabetic patients and the severity of periodontal disease (PD). Materials and
Methods: Study groups included a total of 90 Type II diabetic individuals and were divided as Group I with well-controlled diabetics and Group II with poorly controlled diabetics based on glycosylated hemoglobin levels. The periodontal parameters of all patients, namely probing pocket depth, clinical attachment level, and bleeding on probing oral hygiene index-debris index score, were assessed. The collected data were subjected to statistical analysis.
Results: The periodontal parameters of all patients with poor glycemic control were significantly higher than well-controlled group. There was a significant difference between all clinical parameters between groups with P < 0.001 indicating severe PD in poor glycemic status group.
Conclusion: The severity of PD is related to glycemic status. The poorly controlled diabetic patients had severe periodontitis than well-controlled diabetic patients. Local factors such as dental plaque seem to have a major influence in disease progression. Copyright:

INTRODUCTION

Periodontitis is defined as an inflammatory disease of the periodontium characterized by progressive destruction of supporting structures such as alveolar bone and connective tissue. In addition to the microorganisms and environmental factors, host susceptibility plays a major role in the etiopathogenesis of periodontal disease (PD). Gingivitis is primarily caused by local factors but its progression to PD and its severity depends on the susceptibility of host.[1]

Diabetes mellitus (DM) is defined as a metabolic disorder due to altered glucose metabolism characterized by decreased insulin secretion or action resulting in hyperglycemia and excretion of glucose in urine. Periodontitis is the sixth complication of diabetes according to the American Diabetes Association.[2] In addition to localized deleterious effects, periodontitis can have influence on distant organs.[34] The insulin resistance and the resultant sustained hyperglycemia in prolonged DM results in macrovascular and microvascular complications. Both DM and PD are closely associated with each other as inflammation plays a central role and both these conditions act as metabolic stressors. The presence of DM has deleterious effect on periodontium and vice versa. The study aims to assess the influence of glycemic status on periodontal health.

MATERIALS AND METHODS

The design of the study is case − control. A total of 90 participants were included who were known diabetics under medication. The study consists of two groups. Group I included 45 well-controlled diabetic individuals (hemoglobin A1c [HbA1C] <7) and Group II included 45 poorly controlled diabetic individuals (HbA1C >7). The study was done on diabetic patients who visited the Outpatient Department of Karpaga Vinayaga Institute of Dental Sciences for dental consultation and treatment. Approval from the Institutional Ethics Committee was received before the start of the study. All participants were included in the study after obtaining informed consent.

Inclusion criteria

Patients who were known diabetics for more than a year under medication

Patients who were not having any systemic diseases other than DM

Patients who were not on drugs such as phenytoin, barbiturates, and antibiotics

Patients who have not undergone periodontal treatment in the recent 6 months

Patients were included based on their willingness and interest to participate in the study.

Exclusion criteria

Patients who were on antibiotic therapy in the recent 6 months

Pregnant and lactating mothers

Smokers and alcoholics.

All participants of the study were subjected to periodontal examination by a single examiner. A properly illuminated and well-equipped dental chair was used for examination. Oral examination was done using a calibrated Hu-Friedy William's periodontal probe and mouth mirror. Patient's medical history was collected through a personal interview. Patient's demographic details such as age and duration of diabetes were documented from their respective medical records.

The following periodontal parameters were recorded:

Probing pocket depth (PPD) was measured in each tooth of all quadrants, excluding the third molars and the root stumps. The depth was recorded from all six sites around the teeth. It was measured from the margin of the gingiva to the apical part of the periodontal pocket

Clinical attachment level (CAL) was calculated as the distance from the cementoenamel junction to the depth of the pocket

Bleeding on probing (BOP): After 30 s, following gentle probing with William's probe, BOP was assessed using Gingival Index given by Loe and Silness index. All bleeding sites were added and calculated as percentage

Plaque levels are assessed using Debris Index Score (DI-S) of Simplified Oral Hygiene Index.

Determination of HbA1c levels: Under sterile conditions, venous blood was collected and glycosylated hemoglobin levels were calculated using an AutoAnalyzer.

Statistical analysis

Microsoft Excel sheet was used to compile the data and Statistical Package for the Social Sciences (SPSS), IBM, Chicago, Illinois software program, version 20.0 software was used.

RESULTS

The data showed normal distribution, and therefore, parametric analysis was used. The mean comparison between groups based on age, HbA1c, and gender was done using student's unpaired t-test and Chi-square test, respectively. Age range between 35 and 55 was selected, and the mean age was 44.82 ± 4.93. There was no significant difference between age and gender between groups with P < 0.05. HbA1c values were categorized as <7% (good metabolic control) and >7% (poor metabolic control). There was a significant difference between Group I and II based on HbA1c with a mean of 6.56 and 8.24, respectively [Table 1 and Figure 1].

Table 1

Mean comparison of demographic variables between the groups

	Group	Mean	SD	t	P
Age	I	44.82	4.93	0.994	0.323
	II	43.80	4.83
HbA1c	I	6.56	0.50	−17.05	0.001**
	II	8.24	0.44
Gender		Group		χ 2	P
		I	II
Male		20	19	0.45	0.834
Female		25	26
Total		45	45

P<0.05 statistically significant, P<0.001 highly significant. HbA1c: Hemoglobin A1c, SD: Standard deviation, **P<0.001

Figure 1

Mean comparison between all clinical parameters

BOP, PPD and CAL, and oral hygiene level expressed by DI-S index were the significant predictors of PD. Student's unpaired t-test was used to compare the periodontal parameters between both the groups. Oral hygiene was considered good if the DI-S values were <1 and poor oral hygiene when the DI-S was more than 1. Criteria for periodontitis include the presence of PPD/CAL values above 5 mm. BOP in more than 50% of sites were considered to indicate severe gingivitis.

The mean DI-S score in Group II individuals was 1.20 ± 0.41 indicating poor oral hygiene. The estimated periodontal parameters correlated with the glycemic status of the patients in both the groups. Group II individuals had significantly higher mean values of BOP, PPD, and CAL. Patients with poor glycemic control (Group II) had significantly severe PD than the well-controlled (Group I) [Table 2 and Figure 1].

Table 2

Mean comparison of periodontal parameters between the groups

	Group	Mean	SD	t	P
DI	I	0.73	0.45	−5.19	0.001**
	II	1.20	0.41
BOP	I	41.96	1.46	−27.03	0.001**
	II	51.47	1.85
PPD (%)	I	14.33	3.93	−24.13	0.001**
	II	34.33	3.93
CAL (%)	I	16.78	4.15	−19.62	0.001**
	II	36.44	5.29

P<0.05 statistically significant, P<0.001 highly significant. SD: Standard deviation, DI: Debris index, BOP: Bleeding on probing, PPD: Probing pocket depth, CAL: Clinical attachment level,**P<0.001

DISCUSSION

The current study presents the association between glycemic status and its influence on PDs. In both the study groups, the periodontal parameters were analyzed and compared. According to the results of the present study, the severity of PD is more in patients with poorly controlled DM than in well-controlled DM in relation to all parameters. The results are consistent with the findings of meta-analysis of earlier studies.[5] Patients with higher HbA1c values and poorly controlled DM had more severe PD. Severe periodontal destruction and increased tooth loss were observed in one study with prolonged duration of DM.[6]

Two different opinions exist about the link between DM and PD. One theory believes that in DM, defective PMN function, altered bacterial flora, and microvascular changes will exaggerate the response of periodontium to local factors. Another concept insists that no relationship exists between DM and PD, and the coexistence of both the conditions is just a coincidence without any correlation. This insists PD severity is directly proportional to the amount of local factors.[78]

Alterations in glycemic status are a common characteristic feature of DM. The advanced glycation end products (AGEs) that are formed in hyperglycemia aggravate host response in the presence of periodontal infection resulting in severe PD in diabetics. The function of neutrophils, namely chemotaxis and phagocytosis, is deteriorated in DM resulting in increased persistence of bacteria and periodontal destruction.[910] Furthermore, a hyperresponsive macrophage phenotype is found in hyperglycemia leading to enhanced secretion of proinflammatory mediators in the periodontal pocket. Abnormalities in blood flow are enhanced in hyperglycemia such as increased viscosity of blood, decreased deformability of red blood cells, and increased platelet aggregation, which cause tissue hypoxia. The oxygen-carrying capacity of glycosylated hemoglobin is decreased, thereby reducing tissue perfusion. Hyperglycemia impairs overall cell function, thereby reducing the reparative capacity. In poorly controlled diabetes, the sustained hyperglycemia enhances the formation of AGEs resulting in increased severity of periodontitis.[11] Studies reveal a close association between severity of PD and duration of DM.[12] A close association exists between diabetic status and severity of PD.[13] The present study findings insist that the severity of PD increases with the duration of DM. The mechanism by which periodontitis influence DM is that the predominant Gram-negative anaerobic bacteria and its endotoxin present in deep periodontal pockets enter the systemic circulation to cause hyperglycemia. The proinflammatory cytokines of the destructive periodontal tissue may retard the insulin action leading to metabolic alterations, thereby aggravating insulin resistance. Hence, periodontitis may be considered to be a risk factor in causing poor glycemic control. Thus, in diabetics, increase in the severity of PD may increase blood glucose levels.[14]

CONCLUSION

PD and DM are linked with each other. In a diabetic individual, periodontal health greatly depends on the glycemic control. A good metabolic control will have a better influence in maintaining a good periodontal health. Similarly, the local factors and bacterial endotoxins of periodontitis may influence the metabolic control of diabetic individuals. Prompt periodontal intervention and treatment will help better control DM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.