Influence of Type 2 Diabetes mellitus on periodontal conditions in a population of Dhaka City *

*Corresponding Author: Dr. Salauddin Ahmed BDS, PhD, Associate Professor, Dept. of Periodontology and Oral Pathology, Dhaka Dental College & Hospital E-mail: makto93@gmail.com UpDCJ: 2016;6(1), Dr. Salauddin Ahmed et al. 36 | P a g e advancing age 1-3 . Adult type of periodontitis usually begins after 4 th decade of life with multiple systemic and local factors playing their decisive roles in its etiology. Gingivitis and periodontitis, two most common types of periodontal disease, are as ancient as human history goes. Human skulls from ancient civilizations show evidence of periodontal bony destruction 4 . Both diabetes mellitus (DM) and periodontal diseases are chronic disorders that have a major impact on the health and well-being of millions individuals worldwide 5 . Periodontal disease is the second main cause of oral cavity disorders affecting the population due to its high prevalence 6 .Therefore, if the presence of periodontal diseases plays any role in overall systemic health, the public health impact may be substantial 3 . Evidence consistently reveals that diabetes is a risk factor for increased prevalence of gingivitis and periodontitis 7 . Diabetes results in changes function of immune cells including neutrophils, monocytes, and macrophages. Neutrophil adherence, chemotaxis, and phagocytosis often are impaired 8,9 . Defects in this first line of defense against periodontal pathogens can facilitate bacterial persistence in the periodontal pocket and significantly increase periodontal destruction. In a 2008 review of evidence published since year 2000, Taylor and Borgnakkel 10 validated previously reported conclusions that diabetes is associated with increased occurrence and progression of periodontitis and, further, that periodontal infection is associated with poorer glycemic control in individuals with diabetes. This study was carried out to find out the intensity of periodontal diseases in diabetic patients and compare the results with nondiabetic controls. As this study was conducted using a number of laboratory confirmed diabetic patients, the influence of NIDDM on periodontal status of the participants were also discussed in detail. Methods This clinical study was carried out from January 2014 to December 2015. A total of 132 patients with type 2 diabetes mellitus and 30 nondiabetic controls were included. These type 2 diabetic patients include two age groups, one group 40-55 years (both male-female) considered as middle group and another one 5670 yrs (both male-female) as old age group. First group was divided into two sub-groups one of which consist of 22 patients who were non-drug, lifestyle maintenance therapy (subgroup A) while another sub-group of 22 patients were on oral hypoglycemic drug therapy (subgroup B). The Second age group participants were 56-70 yrs and consist of 22 male and 24 female patients on oral drug therapy. Thirty (n=30) non diabetic persons, 15 each from 40-55 yrs and 5670 years age group respectively were selected as controls. The patients were attending the “New OralDental” clinic, a reputed dental clinic located in Uttara, Dhaka. The participants mostly represented middle to high income members of the society. All the cases for this study were laboratory confirmed diabetics without insulin having >20 remaining teeth. Edentulous patients were not included in this study. A questionnaire about general health and dental care habits was used in combination with the intra-oral examination. Informed consent was obtained from each participant beforehand explaining the purpose and nature of the study. Diabetes mellitus was diagnosed by diabetecian having HbA1C ≥7. Regarding controlling the diabetes, the middle age who were not taking medicine for their condition, informed us that they were very much sincere about routine medical checkup, physical exercise and restricted diet as prescribed by their respective physicians. The oral health examinations were carried out in the “New Oral-Dental” clinic using mouth mirrors, tweezers and ideal periodontal probes calibrated in millimeters with blunt rounded tips to measure periodontal pocket depth (PPD) and clinical attachment loss (CAL). Only one experienced examiner measured the same clinical parameters throughout the study period. All the patients were considered being almost equal in oral health status by using Gingival Index (GI) and Plaque Index (PI). Periodontal pocket depth (PPD) was calculated as the distances in millimeters from the gingival UpDCJ: 2016; 6(1): Influence of Type 2 Diabetes mellitus on periodontal conditions in a population of Dhaka City 37 | P a g e margin to the base of gingival crevice. Clinical attachment loss (CAL) was measured as the distance in mm from cement-enamel junction to the crevice bottom. All clinical measurements were made on 4 sites per tooth (mesial, buccal, distal and lingual/palatal) on all existing teeth except third molars. Periodontitis was considered among patients who had 2 or more teeth with significant clinical attachment loss each of which had a mean CAL score > 1 mm. The mean CAL score of an individual tooth was calculated from adding the pocket depths at 4 sites and then dividing the number by 4. The mean CAL score of a participant was calculated by adding the mean score of the affected teeth divided by the number of affected teeth. Thus the chronic form of periodontal diseases were assessed and categorized depending on the degree of CAL by “AAP international workshop for classification periodontal diseases 1999” 5 .


Introduction
Periodontal diseases are infections of the gums and supporting structures of the teeth.An increase in periodontal pocket depth and attachment loss, regression of junctional epithelium in an apical direction along with bone loss at the alveolar crest level is common manifestations of periodontal disease.Although uncommon among the young adults, the incidence of periodontal disease increases with advancing age [1][2][3] .Adult type of periodontitis usually begins after 4 th decade of life with multiple systemic and local factors playing their decisive roles in its etiology.Gingivitis and periodontitis, two most common types of periodontal disease, are as ancient as human history goes.Human skulls from ancient civilizations show evidence of periodontal bony destruction 4 .
Both diabetes mellitus (DM) and periodontal diseases are chronic disorders that have a major impact on the health and well-being of millions individuals worldwide 5 .Periodontal disease is the second main cause of oral cavity disorders affecting the population due to its high prevalence 6 .Therefore, if the presence of periodontal diseases plays any role in overall systemic health, the public health impact may be substantial 3 .Evidence consistently reveals that diabetes is a risk factor for increased prevalence of gingivitis and periodontitis 7 .Diabetes results in changes function of immune cells including neutrophils, monocytes, and macrophages.Neutrophil adherence, chemotaxis, and phagocytosis often are impaired 8,9 .
Defects in this first line of defense against periodontal pathogens can facilitate bacterial persistence in the periodontal pocket and significantly increase periodontal destruction.In a 2008 review of evidence published since year 2000, Taylor and Borgnakkel 10 validated previously reported conclusions that diabetes is associated with increased occurrence and progression of periodontitis and, further, that periodontal infection is associated with poorer glycemic control in individuals with diabetes.This study was carried out to find out the intensity of periodontal diseases in diabetic patients and compare the results with nondiabetic controls.As this study was conducted using a number of laboratory confirmed diabetic patients, the influence of NIDDM on periodontal status of the participants were also discussed in detail.

Methods
This clinical study was carried out from January 2014 to December 2015.A total of 132 patients with type 2 diabetes mellitus and 30 non-diabetic controls were included.These type 2 diabetic patients include two age groups, one group 40-55 years (both male-female) considered as middle group and another one 56-70 yrs (both male-female) as old age group.First group was divided into two sub-groups one of which consist of 22 patients who were non-drug, lifestyle maintenance therapy (subgroup A) while another sub-group of 22 patients were on oral hypoglycemic drug therapy (subgroup B).The Second age group participants were 56-70 yrs and consist of 22 male and 24 female patients on oral drug therapy.Thirty (n=30) non diabetic persons, 15 each from 40-55 yrs and 56-70 years age group respectively were selected as controls.
The patients were attending the "New Oral-Dental" clinic, a reputed dental clinic located in Uttara, Dhaka.The participants mostly represented middle to high income members of the society.All the cases for this study were laboratory confirmed diabetics without insulin having >20 remaining teeth.Edentulous patients were not included in this study.A questionnaire about general health and dental care habits was used in combination with the intra-oral examination.Informed consent was obtained from each participant beforehand explaining the purpose and nature of the study.
Diabetes mellitus was diagnosed by diabetecian having HbA1C ≥7.Regarding controlling the diabetes, the middle age who were not taking medicine for their condition, informed us that they were very much sincere about routine medical checkup, physical exercise and restricted diet as prescribed by their respective physicians.The oral health examinations were carried out in the "New Oral-Dental" clinic using mouth mirrors, tweezers and ideal periodontal probes calibrated in millimeters with blunt rounded tips to measure periodontal pocket depth (PPD) and clinical attachment loss (CAL).Only one experienced examiner measured the same clinical parameters throughout the study period.All the patients were considered being almost equal in oral health status by using Gingival Index (GI) and Plaque Index (PI).Periodontal pocket depth (PPD) was calculated as the distances in millimeters from the gingival margin to the base of gingival crevice.Clinical attachment loss (CAL) was measured as the distance in mm from cement-enamel junction to the crevice bottom.All clinical measurements were made on 4 sites per tooth (mesial, buccal, distal and lingual/palatal) on all existing teeth except third molars.Periodontitis was considered among patients who had 2 or more teeth with significant clinical attachment loss each of which had a mean CAL score > 1 mm.The mean CAL score of an individual tooth was calculated from adding the pocket depths at 4 sites and then dividing the number by 4. The mean CAL score of a participant was calculated by adding the mean score of the affected teeth divided by the number of affected teeth.Thus the chronic form of periodontal diseases were assessed and categorized depending on the degree of CAL by "AAP international workshop for classification periodontal diseases 1999" 5 .

Discussion
The results showed a significant increase in the disease progression in diabetic patients than in non-diabetic patients (Table 1, 2 & 3).The middle aged (40-55years) drug dependent both male-female demonstrated more disease prevalence than the non-drug dependent same aged group patients (Table 1 &2)).Destructive effects of diabetes mellitus along with aging process were markedly seen in the elderly (56-70 years) group of drug dependent patients compared with non -diabetic controls.Severe form of periodontitis (CAL >4mm) was found in elderly age group, with slightly higher prevalence in female of this age group (male 27.2 % and female 33.3%).All the members of elderly age group were on oral drug therapy.The non-diabetic controls demonstrated GI, PPD and CAL scores less than one (<1) (Table 3), which indicated very little periodontal breakdown in general but 13.3% mild periodontitis and 33.3% mild to moderate periodontitis were recorded in middle age and elderly patients respectively.Among non-drug therapy middle age patients, 54.5% male and 49.9% female were suffering from periodontal disease (Table 1&2).On the other 75% male and 68.1% female patients who were receiving oral drug therapy for diabetes control suffered from the variable degrees of periodontal disease.It is noteworthy that higher incidence of periodontal breakdown were seen in middle age oral drug recipients than in nondrug recipients.
The overall result of this study demonstrated a trend of increased periodontal breakdown in patients suffering from type 2 diabetes mellitus.
Here one question may arise that why drug receiving middle aged group patients apparently had more disease prevalence than non-drug receivers?In this study, the non-drug dependent subjects claimed to maintain their diabetes by regular medical checkup following physical exercise, relatively stress free life and other regularities.It can be assumed that to make glycemic control, one must have regular physical activities, diet restriction and stress free life along with drug therapy.On the other hand, it could be assumed that, drug dependent subjects who showed relatively higher disease prevalence, might not be sincere about their diabetes control thinking in the mind that only drugs could cure the disease.Studies have showed that in combating periodontal disease progression, treatment protocol for diabetes should be accomplished by combined drug and physical therapies (11-13).
Diabetes mellitus induced changes in the capillary basement membrane may have an inhibitory effects on the transport of oxygen white blood cells, immune factors and waste products, all of which could affect tissue repair and regeneration.There is a decreased function of PMNs resulting reduced phagocytosis, impaired adhesion and chemotactic response.An alteration in the constituents and change in flow of gingival crevicular fluid (GCF) has been shown to be associated with diabetes mellitus (14).The presence of periodontal disease in the diabetic subjects suggests that diabetes mellitus and periodontal disease have definitely a strong link between them.Diabetes mellitus increases the risk of periodontitis particularly if poorly controlled.Periodontal treatment has been associated with improvement in glycemic control, though more research is required to investigate this further.Oral health, including periodontal health, is a fundamentally important component of general health and particularly so in diabetes.

Conclusion
The present study showed an increased risk of periodontal damage in NIDDM pts particularly if poorly controlled.This study also revealed more intense periodontal among the drug dependent middle age group compared to nondrug dependent ones.This study also shows an apparent association between ageing process and increased prevalence of periodontitis compared to same healthy population, which needs to be statistically verified.Controlling diabetes by maintenance of life regularities along with proper hypoglycemic drugs could play a role in preservation of periodontal tissues.Further detailed research on this issue is recommended.

Table 1 : Clinical Attachment loss and periodontal breakdown in Type-2 diabetes mellitus (NIDDM) male patients (n=64)
Table1shows that 54.1% non-drug therapy (Gr-A) males in the 40-55 age group had mild to moderate peridontitis, while 75% pt who were on oral hypoglycemic agents ( gr-B) suffered from similar