|
|
 ?  ? |
| ORIGINAL ARTICLE |
|
|
Year : 2014? |? Volume : 3? |? Issue : 1? |? Page : 11-16 |
|
Prevalence and severity of periodontal disease among non-insulin-dependent diabetes mellitus patients in Shimla City, Himachal Pradesh, India
Vinay Kumar Bhardwaj
Department of Public Health Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| Date of Web Publication |
11-Apr-2014 |
Correspondence Address:
Vinay Kumar Bhardwaj
Department of Public Health Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
India
DOI: 10.4103/2278-9588.130431
Background: Periodontal disease has been labelled as the sixth complication of the diabetes. Abnormal collagen metabolism, abnormal polymorphonuclear cell function and altered sulcular microbial flora progresses periodontitis among diabetic patients.
Aim : To find out the prevalence and severity of periodontal disease among Noninsulin-dependent Diabetes Mellitus Patients in Shimla City, Himachal Pradesh, India.
Materials and Methods: The study was conducted among 100 subjects suffering from type-II diabetes mellitus and 100 non diabetic patients attending medicine department with age group between 35 to 75 years. Based on the values of glycated haemoglobin the diabetic subjects were divided into well, moderate and poorly controlled. Information regarding age, gender and duration of diabetes was recorded on the format. CPI index was used to evaluate the periodontal status of the subjects. Data was analysed using SPSS version 15. P ? 0.05 and ?0.01 was considered as statistically significant and highly significant respectively.
Results: Among both the genders, the mean CPI score was higher among diabetics as compared to the nondiabetics. Statistically this difference was highly significant (P < 0.01). HbA 1 C has also shown significant association with the occurrence of higher CPI scores with increase in its value. Longer duration was associated with higher CPI scores than lesser duration and statistically this difference was significant. (P < 0.05).
Conclusion: Type-II diabetic patients have a higher prevalence of periodontal disease than non diabetic individuals. More emphasis is to be put on the co-managemnt of oral and overall health in patients with diabetes by dental and general practitioners.
Keywords:?Diabetes mellitus, glycated hemoglobin, periodontits
How to cite this article:
Bhardwaj VK. Prevalence and severity of periodontal disease among non-insulin-dependent diabetes mellitus patients in Shimla City, Himachal Pradesh, India. J Cranio Max Dis 2014;3:11-6 |
How to cite this URL:
Bhardwaj VK. Prevalence and severity of periodontal disease among non-insulin-dependent diabetes mellitus patients in Shimla City, Himachal Pradesh, India. J Cranio Max Dis [serial online] 2014 [cited?2014 Sep 6];3:11-6. Available from:?https://craniomaxillary.com/text.asp?2014/3/1/11/130431 |
|
??Introduction |
? |
 |
Periodontal diseases are one of the more prevalent oral diseases affecting more than 50% of Indian community. Untreated chronic periodontitis is responsible for tooth loss in majority of the cases. Constant presence of chronic inflammation and inflammatory mediators has also been proved to be a significant risk factor of systemic disease like diabetes mellitus (DM). [1] Epidemiological research indicates that periodontal diseases are widespread throughout the world and evidence exists to show that their extent and severity increases with age. [2] This view of a particularly high prevalence of periodontal diseases appears to have originated from early epidemiological studies using an index system that gave weight to gingivitis and moderate periodontitis resulting from poor oral hygiene and calculus deposition. [3] Albandar and Rams [4] in an overview concluded that subjects of Asian ethnicity had the third highest prevalence of periodontitis. DM, a chronic metabolic diseases characterized by hyperglycemia, is often attributed to environmental and genetic factors. [5] The main types of diabetes are classified primarily on the basis of their underlying pathophysiology. Type 1 diabetes, which constitute 5-10% of all the cases results from autoimmune destruction of insulin producing ?-cells in the pancreas leading to total absence of insulin secretion. Individuals with type 1 idiopathic DM lack immunologic markers indicative of an autoimmune destructive process of the beta cells. However, they develop insulin deficiency by unknown mechanisms and are prone to ketosis. Type 2 diabetes which constitutes about 85-90% of all cases comprises of a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production. Distinct genetic and metabolic defects in insulin action and secretion gives rise to the common phenotype of hyperglycemia in type 2 DM. Type 2 DM is preceded by a period of abnormal glucose homeostasis classified as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). [6] Asia in particular has the highest prevalence of diabetes in the world. Countries exhibiting the fastest rise in diabetic population growth include India and China, among many other developing countries. [7] Diabetes is an alarming public health problem, affecting 245 million people worldwide. Each year seven million individuals develop diabetes and the projection for the year 2030 expects that 366 million people will have the disease worldwide. [8] India leads the world today with the largest number of diabetic patients in any given country. Prevalence of diabetics has increased from 2.1-12.1% since 1970. WHO has issued a warning that India will be the "Diabetes capital of the world". [9] Gingival and periodontal diseases occur in childhood, adolescent and early adulthood, but the prevalence of periodontal disease, tissue destruction, and tooth loss increases with age. [10] Periodontal disease has been labeled as the "sixth complication of the diabetes". [11] There are two different hypotheses. According to one angiopathy, abnormal collagen metabolism, abnormal polymorphonuclear cell function and altered sulcular microbial flora are found in close association with the severity of periodontitis among diabetic patients. [12],[13] Another hypotheses is that no relationship exists between DM and periodontal disease when two conditions exist together. It is a coincidence rather than a specific cause and effect relationship. Severity and distribution of local irritant affects the severity of periodontal diseases among diabetic patients. [14],[15]
No literature exist which depicts the prevalence and severity of periodontal diseases among patients with type 2 diabetes in hilly state of Himachal Pradesh. Hence, this study has been taken up to test the hypothesis that diabetic patients have more severe periodontal disease experience and to ascertain whether there are any differences between well, moderately-controlled, and poorly-controlled diabetics and periodontal disease.
|
??Materials and Methods |
? |
|
This cross-sectional study was conducted among 100 diabetic patients and 100 nondiabetic patients aged between 35 and 75 years age (mean age: 51.075 ? 8.62) attending medicine department in Indira Gandhi Medical College and Hospital. Both the case and control group were having the same age and gender. Both the groups consisted of 52 males and 48 females. Subjects suffering from type 2 DM were included as type 2 DM is more prominent than type 1 DM (85-90 vs 10-15%).
Inclusion criteria
Patients in the age group 35-75 years with at least 20 teeth present, undergoing treatment for diabetes or were diagnosed DM for at least 1 year or more, not suffering from any other systemic disease, nephropathy, or retinopathy, not receiving any medication, that is, cyclosporine, phenytoin, and niphedepine, not undergone any periodontal treatment since last 1 year, willing to participate in the study.
Exclusion criteria
Patients with type 1 insulin-dependent diabetes, history of rheumatic heart disease requiring periodic prophylactic antibiotics, nonsteroid anti-inflammatory drugs, steroids, pregnant and lactating females, and not willing to participate in the study. Value of glycated hemoglobin (HbA 1C ) was used to divide number of diabetic patients as follows: <0.7% = well-controlled diabetics, 0.7-0.8% = moderately-controlled diabetics, >0.8% = poorly-controlled diabetics. Written consent was obtained from all the participating subjects. Information regarding age, oral hygiene practices, and deleterious oral habits was obtained from the patients before examination. HbA 1C values, duration of diabetes into three groups (<5, 6-10, and >10 years), and history of diabetic therapy (oral hypoglycemic drugs, insulin, diet modification, and physical exercise) were obtained from hospital records.
Clinical examination
Relevant history was recorded for all participating subjects. Type III examination as recommended by American Dental Association was conducted [16] and periodontal assessment was done with community periodontal index of treatment needs (CPITN) probe (Hu-Friedy, Chicago, IL, USA). CPI index [17] was used in which the entire dentition was divided into sextant. The teeth examined were 17, 16, and 11, 26, 27, 36, 31, 46, 47. When both or one of the designated molar teeth was present, the worst finding from these tooth surfaces was recorded for the sextant. If no index teeth (i.e., teeth number 17, 16, 11, 26, 27, 36, 31, 46, and 47) were present in a sextant for examination, all the remaining teeth in that sextant were examined. The highest CPI code was recorded in each segment (Code 0: No sign of periodontal disease, Code 1: Gingival bleeding after gentle probing, Code 2: Supragingival or subgingival calculus, Code 3: 4-6 mm (millimeter) deeper periodontal pockets, and Code 4: 6 mm or deeper periodontal pockets). Periodontal status was divided into the CPI code, that is, 0, 1, 2, 3, 4, and X. The data was collected by the single examiner between May 2010 and August 2010.
Statistical analysis
Statistical analysis was done using Statistical Package for Social Sciences version 15 (SPSS Inc, Chicago). Depending upon the type of the variables to be compared, the measures of association employed were Student's t-test and Mann-Whitney's U-test. The precision was calculated for 95% confidence interval. P value of ?0.05 and ?0.01 was considered as statistically significant and highly significant, respectively.
|
??Results |
? |
|
Periodontal examination was carried out using CPITN periodontal probe and scores of different sextants were compared. Comparison was made among different sextants, gender wise and the diabetics and nondiabetics. Results show that among both the genders, the mean CPI score was higher among diabetics as compared to the nondiabetics. Statistically, this difference was highly significant (P < 0.01) [Table 1]. Value of HbA 1C has also shown association with the occurrence of higher CPI scores with increase in its value. Statistically, the difference among diabetics with different HbA 1C values was significant (P < 0.05). The duration of diabetes diagnosed or initiation of antidiabetic therapy has also shown impact on the extent of periodontal disease. Longer duration was associated with higher CPI scores than lesser duration and statistically this difference was significant (P < 0.05) [Table 2].
|
Table 1: Mean CPI scores gender-wise and among diabetic and nondiabetic patients
Click here to view
|
|
Table 2: Mean CPI scores according to glycated hemoglobin status and duration of diabetes
Click here to view
|
|
??Discussion |
? |
|
DM and periodontitis are common multigenic and multifactorial chronic disease with higher incidence at an increased age. Both these conditions negatively affect periodontal health, thus affecting the quality of life. [18] Literature has shown many evidences which have consolidated a bidirectional correlation between diabetes and periodontitis. [14],[15],[19] While DM is an independent risk factor for periodontitis, periodontitis as a chronic inflammation has a negative impact on metabolic control of diabetes. [20]
Earliest study on the association between DM and periodontits among females was conducted by Cohen et al. [21] CPI index was used for the assessment of periodontal status in accordance with various studies. Variables like age, frequency of brushing, oral hygiene aid used, HbA 1 C, and duration of diabetes diagnosed or medication started were assessed in the present study similar to various other investigations. [22],[23]
Cerda et al., [24] and Firatli et al., [25] had concluded that the duration of diabetes was a significant factor for the severity of periodontal disease. Emrich et al., [26] stated that the diabetic status was strongly related both to the prevalence and severity of periodontal disease.
From the findings of the present study, it can be concluded that poorer the control and longer is the duration since the diagnosis established, greater are the number of the sextants affected with the periodontal disease. Similar results were found in the studies conducted by Rajhans et al., [27] and Cerda et al. [24] Karjalainen and Knuuttila [28] had suggested that hyperglycemia impairs overall cell function. It also decreases polymorphnuclear cell chemotaxis, phagocytosis, and intracellular killing of microflora. The oxygen carrying ability of HbA 1 C would be impaired, thereby decreasing tissue oxygenation. Hyperglycemia induces blood flow abnormalities like reduced erythrocyte deformability, increased blood viscosity, and increased platelet aggregation, which further enhances tissue hypoxia. Collectively all the above factors will promote periodontal destruction. [29]
Diabetic therapeutic modalities included in the study were oral hypoglycemic drugs, oral hypoglycemic drugs and insulin, diet restriction, and combination of oral hypoglycemic drugs and diet modification. Majority of diabetic patients were on a combination of hypoglycemic drugs, diet modification, and physical exercise. [30],[31]
Higher value of HbA 1 C depicting the well-, moderate-, and poorly-controlled diabetes has shown impact on the periodontal status of the patients. Poorly-controlled diabetes had shown more severe periodontal destruction than moderately- and well-controlled diabetes. Mean CPI score was higher in diabetics as compared to nondiabetics. Statistically, the association was highly significant. Similar results were found in the study conducted by Nishimura et al. [32] Number of missing teeth is a good indicator of past periodontal disease experiences. In this study, diabetics had more missing teeth than nondiabetics, which is similar to other studies. [14],[33] Chronic periodontal diseases also have potential to aggravate insulin resistance and worsened glycemic control, while periodontal treatment that decreases inflammation may help to diminish insulin resistance. [34],[35]
|
??Conclusion |
? |
|
Present study has revealed that diabetic patients have a higher prevalence of periodontal disease than nondiabetic individuals. Dentist should discuss with their patients the relationship between diabetes and periodontal health, using the evidence as a basis for discussion. Duration of diagnosis of diabetes and initiation of therapy, type of diabetic control depending upon the values of HbA 1 C has shown significant association with the severity of periodontal disease. Recognizing the evidences on the relationship between the oral and systemic health will confront dentist, physician, and other healthcare workers. They should emphasize on the comanagement of oral and overall health in patients with diabetes. Guidelines may be formulated for screening undiagnosed diabetics and the comanagement of the patients with diabetes in the clinical practice of dentistry and oral hygiene.
Limitation and Suggestions
The study is conducted on a smaller and convenient sample. Further randomized, controlled intervention trials are needed to extend the evidence base. Inflammation is a common link between periodontal diseases and diabetes. Further research is needed to clarify how inflammatory periodontal diseases may affect insulin resistance, glycemic control, and the risk of developing other diabetic complications.
|
??Acknowledgement |
? |
|
I thank all the patients who agreed to participate in this study, Principal Indira Gandhi Medical College and Hospital Shimla and H.P. Govt. Dental College and Hospital, Shimla for permitting me to conduct this study.Heartiest thanks to my student Capt. (Dr.) Sunil Kumar Abbot for his unconditional assistance.
?
|
??References |
? |
|
| 1. |
Agarwal V, Khatri M, Singh G, Gupta G, Marya CM, Kumar V. Prevalence of periodontal diseases in India. J Oral Health Comm Dent 2010;4:7-16.??
???? |
| 2. |
Nagarajan S, Pushpanjali K. Self-assessed and clinically diagnosed periodontal health status among patients visiting the outpatient department of a dental school in Bangalore, India. Indian J Dent Res 2008;19:243-6.??
[PUBMED]?? ?? |
| 3. |
Corbet EF. Periodontal diseases in Asians. J Int Acad Periodontol 2006;8:136-44.??
[PUBMED]???? |
| 4. |
Albandar JM, Rams TE. Global epidemiology of periodontal diseases: An overview. Periodontol 2000. 2002;29:7-10.??
???? |
| 5. |
Awuti G, Younusi K, Li L, Upur H, Ren J. Epidemiological survey on the prevalence of periodontitis and diabetes mellitus in Uyghur adults from rural Hotan area in Xinjiang. Exp Diabetes Res 2012;2012:758921.??
???? |
| 6. |
Apoorva SM, Sridhar N, Suchetha A. Prevalence and severity of periodontal disease in type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus) patients in Bangalore city: An epidemiological study. J Indian Soc Periodontol 2013;17:25-9.??
[PUBMED]???? |
| 7. |
Awartani F. Evaluation of the relationship between type-2 diabetes and periodontal disease. Odontostomatol Trop 2009;32:33-9.??
[PUBMED]???? |
| 8. |
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimate for the year 2000 and projection or 2030. Diabetes Care 2004;27:1047-53.??
???? |
| 9. |
Pradeep R, Mohan V. The changing scenario of the diabetes epidemic: Implications for India. Indian J Med Res 2002;116:121-32.??
???? |
| 10. |
Carranza FA, Newman MG. Clinical Periodontology. 8 th ed. India: Prism Books Ltd, Philadelphia: W. B. Saunders Company; 1996.??
???? |
| 11. |
Grossi SG, Skrepanski FB, DeCaro T, Zamon JJ, Cummins D, Genco RJ. Response to periodontol therapy in diabetics and smokers. J periodontal 1996;67:1094-102.??
???? |
| 12. |
Cianciola LJ, Park BH, Bruck E, Mosonvich L, Genco RJ. Prevalence of periodontal disease in insulin dependent diabetes mellitus (juvenile diabetes). J Am Dent Assoc 1982;104:653-60.??
???? |
| 13. |
Sandholm L, Swanlijung O, Rytomaa I, Kaprio EA, Manna J. Periodontol status of Finnish adolescent with insulin dependent diabetes mellitus. J Clin Periodontal 1989;16:617-20.??
???? |
| 14. |
Ervasti T, Knuuttila M, Pohjamo L, Haukipuro K. Relation between control of diabetes and gingival bleeding. J Periodontol 1985;56:154-7.??
[PUBMED]???? |
| 15. |
Hayden P, Buckley LA. Diabetes mellitus and periodontal disease in an Irish population. J Periodontal Res 1989;24:298-302.??
[PUBMED]???? |
| 16. |
Thilander B, Pena L, Infante C, Parada SS, de Mayorga C. Prevalence of malocclusion and orthodontic treatment need in children and adolescent in Bogota, Colombia. An epidemiological survey related to different stages of dental development. Eur J Orthod 2001;23:153-67.??
???? |
| 17. |
Namariyama Y. Relationship between CPI and serum antibodies levels for periodontopathic microorganisms in a rural population in Kagoshima prefecture. J Dent Health 2008;58:44-50.??
???? |
| 18. |
Brown LJ, Brunelle A, Kingman A. Periodontal status in united states, 1988-1991: Prevalence, extent and demographic variation. J Dent Res 1996;75:672-83.??
???? |
| 19. |
Taylor GW. Bidirectional interrelationship between diabetes and periodontal diseases: An epidemiological perspective. Ann Periodontol 2001;6:99-112.??
[PUBMED]???? |
| 20. |
Grossi SG, Genco RJ. Periodontal diseases and diabetes mellitus: A two way relationship. Ann Periodontol 1998;3:51-61.??
???? |
| 21. |
Cohen DW, Friedman LA, Shapiro J, Kyle GC, Franklin S. Diabetes mellitus and periodontal disease: Two-year longitudinal observations. Part I. J Periodontol 1970;41:709-12.??
[PUBMED]???? |
| 22. |
Pontes Andersen CC, Flyvbjerg A, Buschard K, Holmstrup P. Relationship between periodontitis and diabetes: Lessons from rodent studies. J Periodontol 2007;78:1264-75.??
???? |
| 23. |
Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32:281-91.??
[PUBMED]???? |
| 24. |
Cerda J, V?zquez de la Torre C, Malacara JM, Nava LE. Periodontal disease in non insulin dependebt diabetes mellitus. The effect of age and time since diagnosis. J Periodontol 1994;65:991-5.??
???? |
| 25. |
Firatli E, Yilmaz O, Onan U. The relationship between clinical attachment loss and the duration of insulin dependent diabetes mellitus (IDDM) in children and adolescents. J Clin Periodontol 1996;23:362-6.??
???? |
| 26. |
Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in non insulin dependent diabetes mellitus. J Periodontol 1991;62:123-30.??
???? |
| 27. |
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.??
[PUBMED]???? |
| 28. |
Karjalainen KM, Knuuttila ML. The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1996;23:1060-7.??
???? |
| 29. |
Tervonen T, Knuuttila M. Relation of diabetes control to periodontal pocketing and alveolar bone level. Oral Surg Med Oral Path 1986;61:346-9.??
???? |
| 30. |
Borrel LN, Burt BA, Taylor GW. Prevalence and trends in periodontitis in the USA: The [corrected] NHANES, 1988 to 2000. J Dent Res 2005;84:924-30.??
???? |
| 31. |
Chavarry NG, Vettore MV, Sensone C, Sheiham A. The relationship between diabetes mellitus and destructive periodontal disease: A meta-anysis. Oral Health Prev Dent 2009;7:107-27.??
???? |
| 32. |
Nishimura I, Iwamoto Y, Soga Y. The periodontal host response with diabetes. Periodontol 2007; 43:245-53.??
???? |
| 33. |
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.??
???? |
| 34. |
Genco RJ, Grossi SG, Ho A, Nishimura F, Murayama Y. A proposed model linking inflammation to obesity, diabetes and periodontal infections. J Periodontol 2005;76:2075-84.??
???? |
| 35. |
Loos BG, Craandiji J, Hoek FJ, Wertheim-van Dillen PM, van der Velden U. Elevation of systemic markers related to cardiovascular diseases in the peripheral blood of periodontal patients. J Periodontol 2000;71:1528-34.??
???? |
?
?
? [Table 1], [Table 2]
|
|
| ? |
|
|
??Search Pubmed for
