843

The Relationship Between Reduction in

Periodontal Inflammation and Diabetes
Control: A Report of 9 Cases
Miller, * Mary Agnes Manwell, * Dewey Newbold, * Mary Ellen Reding, *
Lawrence S.
Allen Rasheed, * Janet Blodgett,f and Kenneth S. Komman*

The established correlation between diabetes and periodontal diseases and the in-
creasing prevalence Type of II diabetes in the general population indicate that dental
practitioners will probably treat an increasing number of diabetic patients. Despite the
fact that there is little scientific evidence to support the concept, it has been generally
accepted that treatment for periodontal disease in diabetic patients may reduce insulin
requirements and improve metabolic balance. However, to date no one has evaluated the
effects of periodontal therapy on the metabolic state of the poorly-controlled diabetic
patient. The purpose of this pilot study was to evaluate the effect of controlling gingival
inflammation on blood glucose levels as determined by glycosylation of hemoglobin and
albumin. / Periodontal 1992; 63:843-848.

Key Words: Diabetes mellitus/epidemiology; diabetes mellitus/etiology; blood glucose;

periodontitis/epidemiology; periodontitis/therapy; risk factors

Periodontists have long been aware of the apparent impact
of diabetes on the treatment of periodontal disease,16 and
it is very likely that the periodontist will see more diabetic
patients in the future. There are currently 12 to 14 million
diabetics in the United States,7 of whom approximately 80%
are classified as having Type II (non-insulin-dependent) di-
abetes, with the remainder having Type I (insulin-depen-
dent). Type II diabetes is reportedly increasing at a rate of
about 6% per year suggesting that the number of people
with this condition may double every 15 years.7
It has been previously shown in both humans and animal
models, that some of the host defects routinely observed in
patients with diabetes8"13 are risk factors for periodontal
disease. Although the specific pathologies associated with
diabetes, observations by clinicians,14'15 and a few well
designed population studies1619 suggest an increased prev-
alence and/or severity of periodontal diseases in diabetics,
other studies have been unable to confirm that correla-
tion.20,21 Similarly, metabolic control of blood glucose lev-
els has been reported to have varied effects on the periodontal
condition.14'22 The prevalence of diabetes and its probable
influence on periodontal disease suggest that diabetics will
very likely become an increasing part of the patient popu-
lation seen by both general dentists and periodontists.
A substantial body of literature supports the conclusion
*
Department of Periodontics, The University of Texas Health Science
Center, San Antonio.
''Department of Medicine.
that patients with diabetes mellitus have an increased sus-
ceptibility to infection. It is also well documented that acute
infections and inflammatory conditions increase glucose and
insulin utilization and therefore complicate the metabolic
control of diabetes. This factor is of great importance since
it has been shown that diabetic patients who are poorly
controlled may have an increased risk for diabetic compli-
cations, such as ocular and vascular lesions.
Although it has generally been taught that control of peri-
odontal disease is beneficial to diabetic control and may
reduce the insulin requirement,5-6 there is minimal evidence
to support this conclusion or to suggest what magnitude of
an effect might be expected from periodontal therapy. Wil-
liams and Mahan23 found that patients required less insulin
following stabilization of their diabetic condition and peri-
odontal treatment. However, to date, no one has evaluated
the effects of periodontal therapy on the metabolic state of
the poorly-controlled diabetic patient.
The purpose of this pilot investigation was to examine
the effects of the elimination of gingival inflammation on
blood glucose levels, as evaluated by the glycosylation of
hemoglobin and albumin, in poorly-controlled diabetic pa-
tients with Periodontitis. It is hypothesized that the elimi-
nation of inflammation will lead to decreased blood sugar
levels which can then be more easily controlled and/or lead
to a decrease in the amount of insulin required.

844 REDUCTION OF PERIODONTAL INFLAMMATION IN DIABETES CONTROL
MATERIALS AND METHODS
Patients
Approximately 200 patients were screened at The Univer-
sity of Texas Health Science Center at San Antonio Dental
School. Ten patients met the following inclusionary crite-
ria: 1) participants must have been diagnosed with insulin-
dependent diabetes more than 1 year prior; 2) a glycated
hemoglobin ("Glycated hemoglobin" is used synony-
mously with "glycosylated hemoglobin" in the literature,
but has recently become the preferred terminology.) and/or
a glycated albumin level which fell above the normal con-
trol range and thereby considered to be uncontrolled; 3) the
presence of at least 15 natural teeth; 4) moderate to severe
Periodontitis as defined by at least 6 sites with a loss of
attachment of 4 mm or greater (using a force controlled
probe), radiographie evidence of greater than 25% bone loss
in multiple sites, and generalized inflammation; 5) the dem-
onstrated ability to perform self-blood glucose monitoring;
6) the demonstrated ability to keep a diary of blood glucose
levels, illness, and activity levels; and 7) the physical and
mental ability to control their plaque to a clinically accept-
able level.
The exclusionary criteria were as follows: 1) severe di-
abetic complications (greater than stage 1 background di-
abetic retinopathy, loss of limb, or autonomie neuropathy);
2) presence of any contributing dermal infections or indo-
lent bladder infections; 3) any recent change in diabetic
status or change in insulin requirements; 4) any severe den-
tal infections requiring drainage, antibiotics, extractions, or
endodontic therapy; and 5) history of allergic reactions to
tetracycline.
Clinical Evaluation
The clinical examination included an assessment of the
radiographie findings and the recording of clinical indices.
The subjects' periodontal conditions were evaluated using
a force controlled probe* set to consistently deliver a force
of 20 grams. Pocket depth and attachment levels were re-
corded at 6 sites per tooth. Additionally, each site was
evaluated for bleeding upon probing and suppuration. Vis-
ual signs of color, contour, and texture were also recorded.
Blood Glucose Levels
Control of blood glucose levels were evaluated by means
of the glycated hemoglobin and glycated albumin levels.
Fifty milliliters of blood were sent to one of three labora-
tories: 1) The University of Texas Health Science Center
at San Antonio; 2) Smithkline Beecham Laboratory (St.
Louis, Missouri); or 3) Medlab (San Antonio, Texas). All
assays for each patient were performed by the same labo-
ratory throughout the study. Two blood samples were drawn
6 to 14 weeks apart and prior to any oral hygiene instruc-
tions or periodontal treatment. The two pretreatment sam-
*Florida Probe Corp, Gainesville FL.
J Periodontol
October 1992
pies were used to determine the expected change in glucose
metabolism without any periodontal intervention. Two post-
treatment blood samples were drawn during the study. One
sample was taken approximately 4 weeks post-initial ther-
apy and the other sample was taken 8 weeks post-initial
therapy.
Procedure
Each patient was seen 6 times during the study. The treat-
ment protocol was specifically designed to reduce the mi-
crobial challenge as rapidly as possible and to gain control
of the periodontal disease within a time frame that allowed
for few confounding events that might interfere with the
diabetic status of each patient. Blood was drawn on the first
visit to evaluate the glycated hemoglobin and glycated al-
bumin levels and clinical and radiographie assessments were
performed to evaluate the patients' periodontal status. If the
patients had moderate to severe Periodontitis and blood glu-
cose values above the normal range they returned for the
second visit. On this visit, blood was again drawn to es-
tablish a second baseline value. The second baseline sample
was taken at least 6 weeks after the first sample. The sub-
jects were also given oral hygiene instructions and in-
structed in the use of the blood glucose monitor§ for home
monitoring. Clinical indices were then evaluated using a
standardized probe. On the third visit, scaling and root planing
with local anesthetic was performed in one visit. If scaling
and root planing could not be completed in one visit, the
subjects returned within 2 days in order to complete the
treatment. All patients were then instructed to begin home
monitoring and were placed on doxycycline 100 mg (b.i.d.
for the first day and then 1 tab per day thereafter) for 14
days, and a Chlorhexidine rinse11 twice daily for 30 seconds.
Two weeks after completion of scaling and root planing,
patients returned for evaluation of home care and to receive
a prophylaxis. Approximately 4 and 8 weeks following
treatment, patients returned for re-evaluation of the clinical
indices and to have blood drawn to evaluate glycated hemo-
globin and albumin levels. Patients were advised to con-
tinue their normal daily insulin regimen and dietary
requirements as instructed by their physician. Patients were
asked to record any changes in insulin requirements or med-
ications taken during the study.
Self-monitoring of blood glucose values was originally
intended to assist the patients with tracking insulin need.
This procedure was intended to serve as a precaution to
guide insulin dosing if a dramatic change in blood glucose
resulted from the therapy. As is characteristic of the poorly
controlled diabetic, most subjects did not use the monitor
or did so inconsistently; therefore, no data were collected.
None of the patients maintained written diaries of insulin
dosage or blood glucose values.
Following completion of the study, patients were referred
§Glucoscan 3000, Lifescan, Inc., Mountain View, CA.
"Peridex, Procter & Gamble Co., Cincinnati, OH.
Volume 63
Number 10 MILLER, MANWELL, NEWBOLD, REDING, RASHEED, BLODGETT, KORNMAN 845

Table 1. Patient characteristics A. Patients with Consistent Decrease B. Patients with No or Inconsistent
in BOP Decrease in BOP
Positive
Natural % Sites % Sites Treatment
Gender Ethnicity Teeth 4-6 mm > 6 mm Response
M Hispanic 17 28.4 3.9 Yes
M Hispanic 24 8.3 0.0 Yes
M Hispanic 27 6.2 11.1 No
M Anglo 24 16.6 2.1 Yes
M Hispanic 29 39.0 5.7 Yes
F Hispanic 28 14.3 0.0 Yes
F Hispanic 18 21.3 0.0 No
M Anglo 18 16.6 0.0 No
F Hispanic 28 25.0 9.0 No

Pre-Tx

for continued periodontal treatment if they so desired. The
patients were able, at any time, to exit the study if neces-
sary. At no time during the study did the periodontal con-
dition of any patient worsen sufficiently to require intervening
therapy beyond that specified in the experimental protocol.
This clinical study was approved by the Institutional Re-
view Board at The University of Texas Health Science Cen-
ter at San Antonio.
Statistical Analysis
Data on each patient are presented in a descriptive format
due to the small number of cases. In some instances the
means of duplicate pre- and post-therapy glycated hemo-
globin and albumin value were determined and compared
by means of a paired r-test. Although more appropriate
statistical methodologies exist for analysis of repeated mea-
sures data, these methodologies are impractical and essen-
tially meaningless for such a small number of patients.
RESULTS
Patients
Nine of the 10 patients completed the study. The presenting
characteristics of each patient are shown in Table 1. No
significant medical or dental complications occurred during
the monitoring period and all the patients tolerated the treat-
ment procedures well. However, one patient experienced
an allergic reaction approximately 4 days after the initiation
of the Chlorhexidine rinse which manifested as a generalized
mucositis. This condition resolved after the Chlorhexidine
was discontinued and the patient completed the study, rins-
ing with warm saline instead of Chlorhexidine.
Figure 1. The change in bleeding on probing as measured by a constant-
pressure periodontal probe is shown for each of the post-treatment (Post-
Tx) monitoring periods for each patient. Bleeding scores for patients who
had a consistent decrease at both 4 and 8 weeks following therapy are
shown in 1A, with the remaining patients presented in IB.
Therapy produced a reduction in inflammation in 7 of 9
patients, as measured by bleeding on probing. Two patients
exhibited an increase in bleeding on probing.
For the 7 patients who showed an improvement, the mean
pretreatment bleeding on probing was 29.3% ± 20.9 of
the sites with a mean post-treatment bleeding on probing
of 11.0% ± 4.7. Since the primary objective was to assess
the change in metabolic control of patients in whom peri-
odontal inflammation had been controlled, the patients were
divided as shown in Figure 1 based on the consistency of
bleeding reduction. The 5 patients in Figure 1A had a sub-
stantial and consistent improvement in bleeding on probing
through the 8 weeks following therapy. The other four pa-
tients (Figure IB) either had an increase in bleeding or an
inconsistent response to therapy such that they could not
qualify as having consistent improvement in periodontal
inflammation.
Metabolic Parameters
The pretreatment glycated hemoglobin (Fig. 2) values were
unchanged and remarkably stable between the 2 sampling
time points. The glycated albumin values, which are more
affected by short-term glucose fluctuations, varied substan-
tially between the 2 pretreatment samples.
The mean glycated hemoglobin for the 9 patients pre-
treatment was 9.44 ± 1.69 and decreased (P 0.11) to=

9.01 ± 2.01 post-treatment. No change was observed in

Clinical Parameters
The patients presented prior to therapy with bleeding on
probing at a mean of 26.4% of the sites examined. A mean
of 23.1% of the sites per patient had probing depths 3=4
mm and 3.5% of the sites probed >6 mm.
Therapy produced a reduction in bleeding on probing
the glycated albumin value following periodontal therapy
when all patients were included in the analysis.
As seen in Figure 3A, the 5 subjects with a consistent
improvement in bleeding all showed a decrease in glycated
hemoglobin levels post-treatment (mean pretreatment
AiC 8.7%, mean post-treatment 7.8%; <0.01 paired
= =

from 26.4% ± 19.0 (standard deviation) of sites to 16.6%
± 13.1 (P 0.25, paired r-test). A 1.0 mm decrease in
=
the mean probing depth per patient (range: 0.3 mm to 2.0
mm) was observed following treatment.
r-test). Patients with no consistent improvement in bleeding
also showed no change or an increase in glycated hemo-
globin values following therapy (Figure 3B). Mean glycated
albumin levels also decreased in the 5 patients with a con-
 J Periodontol
846 REDUCTION OF PERIODONTAL INFLAMMATION IN DIABETES CONTROL October 1992

%A1C DISCUSSION
13
Periodontitis is a complex multifactorial disease. Similarly
12 diabetes mellitus is a complex metabolic syndrome. It is
11 the complexities of both of these disease processes which
10 may contribute to the controversy found in the literature.
Many investigators have studied oral manifestations of di-
abetic patients,8,14'24 periodontal disease severity,15-19'25"28
immunological responses of diabetic patients,9,10'11 and the
effects of controlling diabetes on the periodontium.6'11'14'20
Diabetes has long been identified by periodontists as a
Pre-Tx
complicating factor in periodontal therapy. Both epidemi-
Sample #1
Pre-Tx
Sample #2
ologie studies16-19 and case reports14,15 have shown diabetes
to be a major risk factor for Periodontitis. The most exten-
Figure 2. Glycated hemoglobin values are shown for each patient at each sive analysis of the relationship between diabetes and Peri-
of the two pretreatment (Pre-Tx) sample times, which were 6 to 14 weeks
apart. odontitis was recently accomplished in a well controlled
comparison between Type II diabetic and non-diabetic Pirna
Indians.19 The presence of diabetes increased the risk of
A. Patients with Consistent Decrease B. Patients with No Decrease
in Bleeding on Probing in Bleeding on Probing developing Periodontitis threefold. Diabetes was found to
A1C A1C increase the prevalence and severity of Periodontitis inde-
Chg
2.5
Chg
2.5 pendent of the effects of age or oral hygiene. Although this
relationship appears to be strong, the compounding varia-
bles inherent in studying two chronic diseases may result
in less clear associations in selected populations.
The impact of diabetes on periodontal diseases is also
evident during therapy. Conventional periodontal therapy
that is directed to reducing the bacterial challenge is less
predictable in poorly-controlled diabetics,15 and the optimal
clinical outcome in a Periodontitis patient with diabetes must
Post-Tx Post-Tx Pre-Tx Post-Tx Post-Tx include control of both the diabetes and the bacterial
4 wks 8 wks 4 wks 8 wks

Figure 3. The glycated hemoglobin is shown for each of the

change in
challenge.15,22,29
post-treatment (Post-Tx) monitoring periods for each patient. Patients are study was initiated as one of multiple pilot projects
This
grouped according to the bleeding response patterns of Figure 1. to explore the relative influence of different variables in the
relationship between diabetes and Periodontitis. This pilot
A. Patients with Consistent Decrease B. Patients with No Decrease
study therefore asked a very simple directed question: If
in Bleeding on Probing in Bleeding on Probing periodontal inflammation in poorly-controlled diabetics can
be controlled is there a reduction in blood glucose values?
Although a small number of patients were involved, this
study appears to demonstrate some association between im-
provement in the periodontal bleeding response and im-
proved metabolic control of blood glucose levels.
The only previous attempt to directly address the value
of periodontal therapy in the metabolic control of diabetes23
used the best technology at the time which included re-
cording of insulin usage. One other report17 noted reduced
diabetic complications and insulin requirement in diabetics
Pre-Tx who were treated for Periodontitis. The present study em-
Figure 4. The change in glycated albumin is shown for each of the post-
ployed the assessment of plasma levels of glycated hemo-
treatment (Post-Tx) monitoring periodsfor each patient. Patients are grouped globin and albumin, to which glucose is attached.30 Since
according to the bleeding response patterns of Figure 1. these levels are a reflection of the chronic exposure of
hemoglobin and albumin to blood glucose as well as the
half-life of these compounds, the assays do not depend upon
sistent improvement in bleeding on probing, but there was patient cooperation and are not greatly affected by blood
more variability in this parameter (Fig. 4). glucose fluctuations on the day of the assay. The glycated
No changes in lifestyle or medications that may contrib- albumin is considered an indicator of blood glucose levels
ute to these findings were recorded for any patients. within the previous 1 to 2 weeks and glycated hemoglobin
 Volume 63
Number 10 MILLER, MANWELL, NEWBOLD, REDING, RASHEED, BLODGETT, KORNMAN
is considered an indicator of blood glucose levels within
the previous 4 to 8 weeks.
Some tetracycline derivatives have produced transient
hypoglycémie effects in diabetics but not in normal sub-
jects. This was most likely not a factor in the results ob-
served in the current study since the post-treatment glycated
hemoglobin measurements were taken 4 and 8 weeks fol-
lowing therapy, and the decrease in blood glucose appeared
to be related to inflammation control.
It is reasonable to conclude from this pilot study that the
metabolic control of diabetics can be altered by controlling
the periodontal inflammation. Three considerations appear
to be important in the appropriate interpretation of this con-
clusion. First, caution must be used in interpreting results
from such a small number of patients. Patients with con-
sistent improvement in bleeding scores had a decrease in
glycated hemoglobin that was not seen in repeated pretreat-
ment samples or in patients with no improvement in bleed-
ing. Although this pattern appeared to be consistent, the
actual magnitude of change in glucose metabolism appeared
to be small. This view is supported by the inconsistent
response of glycated albumin, which is an indicator of short
term glucose control. It therefore seems reasonable to con-
clude that control of periodontal inflammation has the po-
tential to influence glucose metabolism in diabetics but the
clinical and practical significance remains to be determined.
Secondly, periodontal disease is only one factor, and
potentially a relatively minor factor, in the management of
the metabolic control of the diabetic. It is therefore essential
for the periodontist and physician to work in concert to
support patient compliance and to manage those factors
which complicate metabolic control of the patient. Al-
though no overt changes in lifestyle or insulin dosage were
reported by the patients, the study was not designed to
specifically monitor those factors. As such, it may well be
that some patients had medication or lifestyle characteristics
that influenced both the periodontal inflammation or glu-
cose control. It is still of interest that the improvements in
inflammation and blood glucose moved together.
The third consideration in interpreting this report is that
it may not be possible or practical to control the periodontal
disease in all poorly-controlled diabetic patients. The poor
compliance, often times associated with poor metabolic
control, may limit the periodontist's success. Similarly the
host compromise, such as impaired neutrophil function, that
results from poor diabetes control may alter the ability of
the host to respond to periodontal therapy.
It should be noted that the therapy in this study resulted
in clinical improvement in only 5 of 9 patients. The failure
to achieve clinical improvement in some of the patients may
of course be related to multiple factors, such as compliance
with home care or antibiotic therapy, but it is of interest
that 3 of the 4 patients with poor clinical response also had
the highest initial glycated hemoglobin values. With this
group of patients, full mouth scaling and root planing was
847
accomplished in one to two visits within a 2-day period.
Although this may not be the optimal way to deliver care
to diabetic periodontal patients, this approach was consid-
ered necessary to achieve similar time lines for monitoring
the patients. Future studies should evaluate the ability of
different therapeutic approaches to resolve the inflammation
in diabetic patients who appear less responsive to peri-
odontal therapy.
In general this study uses current techniques for moni-
toring blood glucose values that appear to confirm the value
of periodontal therapy as one significant factor in the met-
abolic control of diabetes.
Acknowledgments
The authors very much appreciate the encouragement and
assistance of Ms. Debra Moore, formerly of the Procter &
Gamble Company, in initiating this project; the assistance
of Drs. Sam Miller and Michelle Saunders in the acquisition
of patients; and the research assistance of Ms. Gail Gilbert.
The Glucoscan units were provided by Lifescan, Inc. This
study was supported in part by a grant from Procter &
Gamble Oral Care Product Development, Health and Per-
sonal Care Division, Cincinnati, OH.
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Send reprint requests to: Dr. Kenneth S. Kornman, Department of Per-
iodontics, The University of Texas Health Science Center, 7703 Floyd
Curl Drive, San Antonio, TX 78284-7894.
Accepted for publication April 28, 1992.