Indian Journal of Dental Research, 22(2), 2011 291

Received : 19-12-09
Review completed : 19-05-10
Accepted : 25-09-10
ORIGINAL RESEARCH
Periodontal treatment needs in diabetic and non-diabetic
individuals: A case-control study
Manas Das, Upadhyaya V
1
, Srinivas Sulugodu Ramachandra, Jithendra KD
ABSTRACT
Aim: Diabetes mellitus is a chronic metabolic disorder of the carbohydrate, protein and fat
metabolism, resulting in increased blood glucose levels. Various complications of diabetes have
been described with periodontitis being added as the sixth complication of diabetes mellitus.
The aim of this study was to assess periodontal status and treatment needs (TN) in diabetic
patients and to compare the findings between diabetic and non-diabetic individuals using
community periodontal index (CPI).
Materials and Methods: We evaluated the periodontal status and periodontal TN in diabetic and
non-diabetic individuals in Guwahati, Assam. A total of 459 (223 diabetic and 236 non-diabetic)
individuals were assessed. A person was considered to be diabetic when his blood glucose
levels were above 140 mg/dl under fasting condition and 200 mg/dl 2 hours postprandially.
Periodontal status was assessed using CPI.
Results: Periodontal destruction was found to be increased in diabetic individuals, with
periodontal destruction increasing with increased blood glucose levels. The necessity of complex
periodontal treatment also increased with increasing blood glucose levels.
Conclusions: Individuals with diabetes are more prone to periodontal destruction, and hence,
regular periodontal screening and treatment is essential in these individuals.
Key words: Community periodontal index scores, diabetes mellitus, periodontal disease
Department of Periodontics,
Kanti Devi Dental College
and Hospital, Mathura,
Uttar Pradesh and
1
Regional
Dental College and Hospital,
Guwahati, Assam, India
as the sixth complication of diabetes.
[4]
Several authors have
tried to study the relationship of diabetes and periodontal
disease, with a majority of the studies done throughout
the world suggesting that diabetics are at increased risk for
periodontitis.
[5-7]
These studies also highlight the need for
comprehensive periodontal treatment in patients suffering
from diabetes as compared to non-diabetic individuals.
[5-7]
The aim of this study was to assess periodontal status and
treatment needs (TN) in diabetic patients and to compare
rhe hndings Lerveen diaLeric and non-diaLeric individuals
using community periodontal index (CPI). In this study, an
attempt was made to compare the periodontal health status
and TN among diabetic and non-diabetic patients.
Studies have suggested that presence of diabetes might
favor the speedy progression of the periodontal disease
with extensive destruction. Six major complications of
diabetes have been described as retinopathy, nephropathy,
neuropathy, macrovascular disease, altered or delayed
wound healing and periodontal disease.
[4]
Increased amount
of periodontal destruction has been postulated to be due
to increased production of advanced glycation (AGE)
end products and polyol pathway mechanism (Glucose is
reduced to sorbitol by the enzyme aldose reductase. Sorbitol
is considered as a tissue toxin; accumulation of sorbitol leads
Oral health is an integral part of general health. Many
systemic diseases have manifestations in the oral cavity and
in turn many oral diseases do have systemic manifestations.
Ir is righrly said Ly Sir William Osler rhar oral healrh is rhe
mirror of general health.
[1]
Diabetes mellitus is a disorder
characterized by altered glucose tolerance or impaired
carbohydrate, protein and lipid metabolism. There are
currently over 150 million people with diabetes worldwide
and rhis hgure is projecred ro rise ro 300 million Ly 2025
AD.
[2]
According ro World Healrh Organizarion (WHO),
one in six diabetics in the world reside in India.
[3]
Diabetes
can involve and affect several organs of the body, resulting
in specihc complicarions. Feriodonral disease is considered
Address for correspondence:
Dr. Manas Das
E-mail: manas_doll@rediffmail.com
Access this article online
Quick Response Code:
Website:
www.ijdr.in
PMID:
***
DOI:
10.4103/0970-9290.84307
292 Indian Journal of Dental Research, 22(2), 2011
Periodontal treatment needs in diabetic individuals Das, et al.
ro increased inrracellular osmolariry and inux of varer and
osmotic cell injury.).
[8]
This alters the collagen homeostasis
of the periodontium, leading to the formation of more
mature or old collagen. This old collagen is not destroyed
by proteases (collagenases) and other host enzymes, whereas
the newer collagen formed is of immature variety which is
susceptible to rapid breakdown.
[2]
MATERIALS AND METHODS
The present study was conducted in diabetic patients
visiting Guwahati Medical College and Hospital, Guwahati,
Assam, and non-diabetic patients attending Regional Dental
College, Guwahati, Assam, to assess the periodontal status
by using a CPI probe aided by a mouth mirror and to
compare rhe hndings of diaLerics virh rhose of non-diaLeric
individuals. A person was considered to be diabetic when
his blood sugar levels were above 140 mg/dl under fasting
condition and 200 mg/dl 2 hours postprandially.
[9]
All
required and relevanr informarion regarding rhe diaLeres
status were obtained from hospital records. The study sample
consisted of 223 diabetic patients and a control group of 236
non-diabetic individuals. Patients with any other systemic
diseases like hypertension, epilepsy, etc., were not included
in the study. Those who were on antimicrobial medication
and had undergone any periodontal therapy during past 6
months were excluded from the study. The control group
consisted of non-diabetic patients attending Regional Dental
College, Guwahati, Assam, who were age-matched pairs
from the same geographic location (Guwahati, Assam) and
from government hospitals.
CPI was used for the assessment of periodontal health status
and TN. This is the standard index to assess the periodontal
healrh srarus and TN as recommended Ly WHO.
[10]
The
periodontal probing was done on the index teeth by gently
inserting the tip of the probe into sulcus or periodontal
pocket to the full depth. A probing force of not more than
25 gms was used. The direction of the CPI probe during
insertion was kept as parallel as possible with long axis of
the tooth.
Blood glucose analysis was done and according to blood
glucose level, the subjects were grouped arbitrarily as shown
in Table 1.
Statistical analysis
Dara vere srasrisrically analyzed using SFSS for Windovs
(version 11.5, SPSS Inc., Chicago, IL, USA). Descriptive
analysis was done to assess the mean number of sextants
with CPI scores of 0, 1, 2, 3 and 4 with postprandial blood
glucose levels and TN in both the groups. Z test was used to
assess the distribution of mean number of sextants in both
the groups. P value 0.05 vas considered as srarisrically
signihcanr.
RESULTS
The present study using the CPI was carried out on a total
of 459 subjects [223 diabetic (161 males and 62 females)
and 236 non-diabetic (133 males and 103 females)]. The
collected data were statistically analyzed and the observation
and results were tabulated. The number of sextants in
various categories of the CPI scores is given in Table 2. The
distribution of mean score of sextants in diabetic cases and
non-diabetic cases is given in Table 3.
The distribution of sextant of cases based on postprandial
blood glucose levels and CPI scores is given in Table 4. The
distribution of TN of diabetic and non-diabetic individuals
is given in Table 5.
DISCUSSION
Diabetes mellitus is a chronic metabolic disorder, the
incidence of which is increasing due to population
growth, aging, urbanization, and increasing prevalence of
obesity and physical inactivity.
[3]
India with its increasing
population serves as one of the major centers for diabetic
patients. In the last few decades, many epidemiological
studies have been done to understand the relationship
between diabetes and oral diseases and the results have
Leen found conicring and conrradicrory in narure, vhich
guarantees that future research is yet to be done in this
regard.
Table 1: Subjects grouped based on their blood glucose
levels
Fasting (mg/dl) Postprandial (mg/dl)
A1: 141160 B1: 201220
A2: 161180 B2: 221240
A3: 181200 B3: 241260
A4: 201220 B4: 261280
A5: >220 B5: >280
Source data from American Diabetes Association: Diabetes Care 26
(suppl 1): 5, 2003
Table 2: Distribution of sextant in diabetic cases and non-
diabetic cases by CPI score
Score Sextant of diabetic
cases
Sextant of non-diabetic
cases
Number (%) Number (%)
0 85 6.54 377 27.45
1 169 13.0 392 28.55
2 568 43.72 434 31.60
3 333 25.63 131 9.54
4 144 11.08 39 2.84
Total 1299 100 1373 100
CPI = Community periodontal index
Table 3: Distribution of mean score of sextants in diabetic
cases and non-diabetic cases
No. of sextants Mean scoreSD P value
Diabetic cases 1299 2.210.68 Z=28.30
Non-diabetic 1373 1.320.92 P<0.001
Indian Journal of Dental Research, 22(2), 2011 293
Periodontal treatment needs in diabetic individuals Das, et al.
Periodontal health status
On individual evaluation of CPI scores, the number of
sextants with healthy periodontium among diabetics (6.54%)
was less when compared with non-diabetics (27.4%). The
percentage of sites with the scores as bleeding and calculus
among non-diabetics was 28.5 and 31.6%, respectively,
when compared to diabetics with values of 13.0 and 43.7%,
respectively. Campus et al. conducted a similar study in
Sardinian adults and found that diabetic individuals were
at more risk of periodontal destruction as compared to non-
diabetic individuals.
[5]
Periodontal pockets (both shallow and deep) were more
prevalent among the diabetics when compared to non-
diaLerics. This vas similar ro rhe hndings of previous srudies.
The aLove hndings conhrm rhar more sexranrs of diaLeric
subjects are affected by the severe degree of periodontal
disease manifested as deep pockets but among non-diabetics
more number of sextants are affected by the relatively lower
degree of disease manifested as bleeding. In Table 3, it is
seen that mean score of sextant in diabetic was 2.210.68
and in non-diabetics it was 1.320.92. Diabetics were found
to have more mean score when compared to non-diabetics.
This difference is srarisrically signihcanr (P<0.001). Bacic
et al. had applied CPI index in their study. Since it is almost
similar, this comparison is valid.
As given in Table 4, the percentage of healthy condition or
mild destruction (i.e., score 1) decreases as postprandial sugar
level increases. On the other hand, the percentage of higher
level of destruction (i.e., CPI scores 3 and 4) increases with
increasing sugar level. Studies have reported that diabetics
with poor metabolic control have a higher prevalence and
more extensive periodontitis than diabetics who maintain
good control.
[11-13]
Previous studies have shown that well-
controlled diabetic patients had better periodontal health
than the poorly controlled, and that within the diabetic
group the prevalence of periodontal pocket declined as the
control of diabetes improved.
[11-13]
Treatment needs
Oral hygiene insrrucrions and scaling vere required for all
subjects, i.e., needed by 69.9% of the diabetic group and
45.3% of non-diabetic group. In Table 5 it is seen that a
vast majority of diabetic cases, i.e., about 70% need TN 3
(complex treatment), followed by TN 2 (20.1%; scaling and
removing of plaque rerenrive facrors), Lur in non-diaLeric
cases 45.3% need TN 3, followed by TN 2 (28.3%).
CONCLUSIONS
More diabetic subjects were affected by severe degree of
periodontal disease manifested as deep pockets while in
non-diabetics more number of subjects was affected by
relatively lower degree of disease manifested as bleeding
and calculus. Majoriry of diaLeric suLjecrs required complex
periodontal treatment. Diabetes can have an adverse effect
on oral health and periodontal health.
[14]
Good oral health
improves glycemic control and may contribute to the
prevention of long-term complications of the disease. The
dental team can play an important role of recognizing the
signs of undiagnosed diabetes and refer these patients for
further medical investigation and treatment.
[14]
REFERENCES
1. Osler W. Occupational Disease of Teeth. In: Carrol Chouinard MA,
editor. The American Peoples Encyclopedia. Chicago: Spencer Press
Inc; 1971: 191.
2. Ryan ME. Diagnostic and therapeutic strategies for the management of
the diabetic patient. Compend Contin Educ Dent 2008;29:32-8, 40-4.
3. Available from:http://www.who.int/entity/diabetes/actionnow/en/
mapdiabprev.[Last accessed on 2009 Dec 14.]
4. Le H. Periodontal disease: The 6th complication of diabetes mellitus.
Diabetes Care 1993;16:329-34.
5. Campus G, Salem A, Uzzau S, Baldoni E, Tonolo G. Diabetes and
Table 4: Distribution of sextant of cases by postprandial sugar levels and CPI score
Blood sugar level (mg/dl) CPI scores
0 1 2 3 4 Total sextant
B1 (201220) 38 (14.7) 61 (31.4) 122 (47.3) 16 (6.2) 1 (0.38) 258 (100)
B2 (221240) 15 (5.74) 27 (10.3) 136 (52.1) 69 (26.4) 14 (5.4) 261 (100)
B3 (241260) 15 (5.6) 37 (13.9) 116 (43.6) 73 (27.4) 25 (9.4) 266 (100)
B4 (261280) 6 (2.4) 16 (6.4) 108 (43.5) 80 (32.2) 38 (15.3) 248 (100)
B5 (>280) 11 (4.1) 8 (3.0) 86 (32.3) 95 (35.7) 66 (24.8) 266 (100)
Total score 85 (6.5) 169 (13) 568 (43.7) 333 (25.6) 144 (11) 1299 (100)
Figures in parentheses indicate the sextant in percentage; blood tests were done using the Klett Summerson Photoelectric colorimeter model 900,
CPI = Community periodontal index
Table 5: Distribution of diabetic and non-diabetic cases according to different TN
Sex Diabetic Total Non-diabetic Total
TN 0 TN 1 TN 2 TN 3 TN 0 TN 1 TN 2 TN 3
Male 0 (0) 19 (11.8) 36 (22.4) 106 (65.8) 161 0 (0) 15 (11.2) 35 (26.3) 83 (62.4) 133
Female 1 (1.6) 2 (3.2) 9 (14.5) 50 (80.6) 62 7 (6.7) 40 (38.8) 32 (31) 24 (23.3) 103
Total 1 (0.45) 21 (9.4) 45 (20) 156 (69.9) 223 7 (2.9) 55 (23.3) 67 (28.3) 107 (45.3) 236
Figures in parentheses indicate the diabetic and non-diabetic cases in percentage; blood tests were done using the Klett Summerson Photoelectric colorimeter
model 900
294 Indian Journal of Dental Research, 22(2), 2011
periodontal disease: A case-control study. J Periodontol 2005;76:
418-25.
6. Bakhshandeh S, Murtomaa H, Mofid R, Vehkalahti MM, Suomalainen
K. Periodontal treatment needs of diabetic adults. J Clin Periodontol
2007;34:53-7.
7. Almas K, Al-Qahtani M, Al-Yami M, Khan N. The relationship between
periodontal disease and blood glucose level among type II diabetic
patients. J Contemp Dent Pract 2001;2:18-25.
8. Gustke CJ. Treatment of periodontitis in the diabetic patient. A critical
review. J Clin Periodontol 1999;26:133-7.
9. Diagnosis of diabetes accessed on National Diabetes information
Clearing house Available from:http://www.diabetes.niddk.nih.gov/dm/
pubs/diagnosis/ [Last accessed on 2009 Dec 18].
10. Bacic M, Plancak D, Granic M. CPITN assessment of periodontal disease
in diabetic patients. J Periodontol 1988;59:816-22.
Periodontal treatment needs in diabetic individuals Das, et al.
11. Firatli E. The relationship between clinical periodontal status and
insulin-dependent diabetes mellitus. result after 5 yrs. J Periodontal
1997;68:136-40.
12. Kinane DF, Chestnutt IG. Relationship of diabetes to periodontitis. Curr
Opin Periodontol 1997;4:29-34.
13. Karjalainen KM, Knuuttila ML, Von Dickhoff KJ. Association of the
severity of periodontal disease with organ complications in type 1
diabetic patients. J Periodontol 1994;65:1067-72.
14. Fiske J. Diabetes mellitus and oral care. Dent Update 2004;31:190-6.
How to cite this article: Das M, Upadhyaya V, Ramachandra SS, Jithendra
KD. Periodontal treatment needs in diabetic and non-diabetic individuals: A
case-control study. ndian J Dent Res 2011;22:291-4.
Source of Support: Nil, Conict of Interest: None declared.
Copyright of Indian Journal of Dental Research is the property of Medknow Publications & Media Pvt. Ltd. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.