Bull Tokyo Dent Coll (2016) 57(2): 97–104

Case Report doi:10.2209/tdcpublication.2015-0041

Periodontal Regenerative Therapy in Patient with Chronic

Periodontitis and Type 2 Diabetes Mellitus: A Case Report

Fumi Seshima1), Makiko Nishina2), Takashi Namba3) and Atsushi Saito1)

1)
Department of Periodontology, Tokyo Dental College,
2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan
2)
Department of Internal Medicine, Tokyo Dental College Ichikawa General Hospital,
5-11-13 Sugano, Ichikawa, Chiba 272-8513, Japan
3)
Namba Dental Clinic,
3-11-1 Akasaka, Minato-ku, Tokyo 107-0052, Japan

Received 21 December, 2015/Accepted for publication 12 January, 2016

Abstract
We report a case of generalized chronic periodontitis and type 2 diabetes mellitus
requiring periodontal treatment including regenerative therapy. The patient was a
66-year-old man who presented with the chief complaint of gingival inflammation and
mobile teeth in the molar region. He had been being treated for type 2 diabetes mellitus
since 1999. His glycated hemoglobin (HbA1c) level was 7.8%. An initial examination
revealed sites with a probing depth of ≥7 mm in the molar region, and radiography
revealed angular bone defects in this area. Based on a clinical diagnosis of generalized
chronic periodontitis, the patient underwent initial periodontal therapy. An improvement
was observed in periodontal conditions on reevaluation, and his HbA1c level showed
a reduction to 6.9%. Periodontal regenerative therapy with enamel matrix derivative
was then performed on #16, 26, and 27. Following another reevaluation, a removable
partial denture was fabricated for #47 and the patient placed on supportive periodontal
therapy (SPT). To date, periodontal conditions have remained stable and the patient’s
HbA1c level has increased to 7.5% during SPT. The results show the importance of
collaboration between dentist and physician in managing periodontal and diabetic
­conditions in such patients.
Key words: Chronic periodontitis — Diabetes mellitus — Periodontal regeneration — 
Enamel matrix derivative

Introduction health concern in Japan5). In one study, the

The signs and symptoms of periodontal
disease are recognized as the sixth complica-
tion of diabetes mellitus (DM)6). Increasing
prevalence of type 2 (T2) DM is a major
rate of periodontal disease in individuals with
T2DM was found to be 2.6 times that observed
in those without7). Diabetes mellitus has an
adverse effect on periodontal health, and
periodontal disease in turn affects glycemic

97
98 Seshima F et al.
Fig.  1  Oral view at first visit
control and the incidence of complications
from diabetes13).
Periodontal medicine is defined as “a
rapidly emerging branch of periodontology
focusing on the wealth of new data establishing
a strong relationship between periodontal
health or disease and systemic health or dis-
ease”14). Therefore, the two-way relationship
between DM and periodontitis10) is a prime
issue in the field of periodontal medicine, with
effective periodontal treatment important in
diabetic care and vice versa.
Here we report a case of chronic peri­
odontitis and T2DM requiring periodontal
treatment including regenerative therapy.
Case Report
Written informed consent was obtained
from the patient for inclusion in this report.
1. Examination at first visit
In February 2014, a 66-year-old man was
referred to the Clinic of Conservative Dentistry
at Tokyo Dental College Suidobashi Hospital
with the chief complaint of gingival inflam-
mation and mobile teeth in the molar region.
The patient had been receiving treatment for
T2DM since 1999. Treatment had included
educational hospitalization (twice) and medi-
cation for glycemic control. At the time of his
first visit to our clinic, the patient had been
visiting his physician regularly, and had been
prescribed glimepiride, metformin hydro-
chloride, sitagliptin, and pioglitazone hydro-
chloride. His glycated hemoglobin (HbA1c)
level was 7.8% and fasting plasma glucose
level 183 mg/dl. The patient also had hepatitis
B, which had been treated with antiviral
entecavir. The virus was below detection level,
however, at the first visit to our clinic.
The patient had been receiving regular
dental check-ups since his early 40’s. In 2013,
however, he experienced pain in the molar
area. His dentist referred him to our clinic
for the treatment of periodontitis. Figure 1
shows an oral view obtained at his first visit.
 Regenerative Therapy for DM Patient 99

Fig.  2  Periodontal examination at first visit

Fig.  3  Radiographic view at first visit

Gingival inflammation was mostly evident in
the molar region. Extrusion of #17 due to the
loss of #47 and premature occlusal contact of
#27 and 37 were observed.
The results of the periodontal examination
are shown in Fig. 2. Thirty-one percent of
sites had a probing depth (PD) of ≥4 mm and
4.9% a PD of ≥7 mm. Bleeding on probing
was observed in 15% of sites. The level of
plaque control as assessed by the O’Leary
plaque control record (PCR)8) was 32%.
Radiographic examination (Fig. 3) revealed
generalized horizontal and angular bone loss
in #16, 26, 27, and 37. As a measure of patient-
reported outcome, oral health-related quality
of life (QoL) was assessed using an oral
health-related QoL instrument (OHRQL)11).
The total OHRQL score in this patient was 10.
A clinical diagnosis of generalized chronic
periodontitis was made according to the
classification of the American Academy of
Periodontology1).
2. Treatment plan
1) Initial periodontal therapy
This comprised instruction on maintaining
oral hygiene, quadrant scaling and root
planing (SRP), extraction of an impacted
third molar (#38), and occlusal adjustment
for #27 and 37.
2) Reevaluation
3) Periodontal surgery for sites with a PD of
≥4 mm
4) Treatment for recovery of oral function
This comprised prosthetic treatment for
loss of #47.
5) Supportive periodontal therapy (SPT) or
maintenance
100 Seshima F et al.

Table  1  Treatment process

Periodontitis Diabetes (by physician)

February 2014 Initial periodontal therapy Medical diet
· Oral hygiene instruction Exercise therapy
· Quadrant SRP Medication (–May 2015)
· glimepiride (1 mg/d)
June 2014 (Reevaluation) · metformin hydrochloride (500 mg/d)
· re-SRP (#11–14, 37, 41) · sitagliptin (50 mg/d)
· Extraction (#38) · pioglitazone hydrochloride (30 mg/d)
July 2014 Surgical periodontal therapy
· Regenerative therapy with EMD and
autogenous graft (#16)
· Regenerative therapy with EMD alone
(#26, 27)
(Reevaluation)
Treatment for recovery of oral function
· Removable partial denture (#47)
April 2015– (Reevaluation)
present
SPT
· Oral hygiene instruction Medication ( June 2015–present)
· Professional tooth cleaning · repaglinide (0.75 mg/d)
· metformin hydrochloride (500 mg/d)
· sitagliptin (50 mg/d)
· pioglitazone hydrochloride (30 mg/d)
SRP: scaling and root planing; EMD: enamel matrix derivative; SPT: supportive periodontal therapy

3. Treatment process 2) Periodontal surgery

An outline of the treatment process is
shown in Table 1.
1) Initial periodontal therapy
After obtaining informed consent for the
proposed treatment plan, instruction was given
on maintaining oral hygiene and quadrant
SRP performed. Occlusal adjustment was
implemented for #27 and 37. Subsequent
reevaluation revealed a reduction in the PCR
score to 18% and a decrease to 12 and 4%
for sites with a PD of ≥4 mm and ≥7 mm,
respectively. The OHRQL total score was 4.
The patient’s HbA1c level showed a reduction
to 6.9%. Therefore, it was decided to extract
#38 for prophylactic reasons. The extraction
was performed at the Department of Oral
Surgery of our hospital. Re-SRP was imple-
mented for #11–14, 37, and 41.
Tooth #16 contained a deep intrabony
defect 8 mm in depth and 3 mm in width.
Therefore, regenerative therapy with enamel
matrix derivative (EMD; Emdogain® Gel,
Straumann Japan, Tokyo) was implemented
in combination with a autogenous bone graft
(Fig. 4). The autogenous bone was harvested
from the adjacent area using a bone scraper.
Regenerative therapy with application of EMD
alone was performed in #26 and 27.
3) Treatment for recovery of oral function
The mandibular right molar area was
treated with a removal partial denture, as the
patient chose not to have dental implant
treatment.
4) Supportive periodontal therapy
An improvement was observed in gingival
inflammation and PD at reevaluation. Various
 Regenerative Therapy for DM Patient
(a)
(b)
Fig.  4  During regenerative therapy for #16
(a) after debridement, (b) filling of defects with
Emdogain® Gel and autogenous bone graft
levels of improvement were observed radio-
graphically at those sites selected for regen-
erative therapy. There was resolution of tooth
mobility in #37. The periodontal conditions
were judged to be stable, and the patient
was placed in a recall system for SPT. The
total OHRQL score was 4, indicating an
improvement in QoL from at first visit. During
the first 3 months, the patient was recalled
monthly.
At 7 months from the start of SPT, peri-
odontal conditions were still stable (Figs. 5–7).
In terms of clinical outcome of regenerative
therapy, PD showed a reduction of ≥4 mm
from the values at first visit at all sites treated
(Table 2). The level of gain in clinical
attachment at the treated sites varied from
1 to 4 mm.
During SPT, the patient’s HbA1c level
101
showed a tendency to increase (Table 3), and
his physician placed him on repaglinide
instead of glimepiride (Table 1). Professional
tooth cleaning including subgingival plaque
control has been being performed on teeth
with a PD of ≥4 mm at each visit for SPT.
Discussion
The present case was one of generalized
chronic periodontitis accompanied by T2DM.
Periodontal treatment including regenerative
therapy was implemented to reduce inflam-
mation and periodontal pockets. The patient
had a history of educational hospitalization
due to poor glycemic control. On the patient’s
first visit to our hospital, it was surmised that a
combination of DM and less than optimal oral
hygiene had contributed to the periodontal
destruction observed.
One meta-analysis investigating the effect
of periodontal therapy on glycemic control
in T2DM patients revealed a mean decrease
of 0.36% in HbA1c compared to with no
­treatment3). The present patient showed an
improvement of −0.9% in his HbA1c fol­
lowing initial periodontal therapy, which is
consistent with this earlier finding. As we
reported previously9), such an improvement
could be attributed to a combination of
non-surgical periodontal therapy and diabetic
treatment by a physician.
The status of glycemic control is an impor-
tant factor in selecting options for periodontal
treatment. According to the guidelines of
the Japanese Society of Periodontology4), an
HbA1c level of 6.9% is suggested to be the
adequate threshold level of glycemic control
for periodontal surgery. In the present case,
we implemented periodontal surgery after
confirmation of an improvement in HbA1c
following non-surgical periodontal therapy.
On the other hand, the guidelines recom-
mend that regenerative therapy be avoided
in patients with DM if glycemic control is
poor. Indeed, they state that evidence is still
lacking on the long-term clinical outcome
of regenerative therapy in individuals with
102 Seshima F et al.

Fig.  5  Oral view after 7 months of supportive periodontal therapy (SPT)

Fig.  6  Periodontal examination after 7 months of SPT

DM. In a recent study employing an in vivo
diabetic model, Bizenjima et al. reported that
regenerative therapy using fibroblast growth
factor (FGF)-2 had a beneficial effect on
new bone formation in surgical periodontal
defects, increasing cell proliferation and
regulating angiogenesis2). On the other hand,
no beneficial effect was observed on new bone
and cementum formation during short-term
healing with application of EMD in a similar
in vivo diabetic model12). More pre-clinical
and clinical studies are necessary to optimize
periodontal regeneration in patients with
various levels of glycemic control.
It is important to assess the patient’s
systemic condition at each phase of peri­
odontal treatment. In this regard, it has been
reported that sharing of information between
 Regenerative Therapy for DM Patient 103

Fig.  7  Radiographic view after 7 months of SPT

Table  2  Clinical outcome of regenerative therapy with EMD: change in PD and CAL

PD (mm) CAL (mm)

Treated tooth
First visit 7M SPT Change First visit 7M SPT Change
#16 10 5 5 10 6 4
#26  7 3 4  7 4 3
#27  9 5 4  9 8 1

Measured at target (deepest) site

EMD: enamel matrix derivative; PD: probing depth; CAL: clinical attachment level;
SPT: supportive periodontal therapy

Table  3  Change in HbA1c and FPG levels during periodontal treatment

First visit Post-IP Post-surgical SPT: start SPT: 7M

(Feb 2014) ( June 2014) (Feb 2015) (April 2015) (Nov 2015)
HbA1c (%) 7.8 6.9 7.0 7.3 7.5
FPG (mg/dl) 183 118 118 127 147

IP: initial periodontal therapy; SPT: supportive periodontal therapy; HbA1c: glycated hemoglobin;
FPG: fasting plasma glucose

the periodontist and physician is critical in
effectively treating periodontitis and DM9). In
the present case, such cooperation resulted
in an improvement in both periodontal and
diabetic conditions. An increase was observed,
however, in the patient’s HbA1c level during
SPT, the exact cause of which is unclear.
One of the goals in providing periodontal
treatment is to reduce PD to ≤3 mm at all
sites requiring surgery. This was not possible,
however, in the present patient as periodontal
breakdown was too advanced at such sites at
his first visit, and even included furcation
involvement. The present case supplies further
evidence that careful SPT and continuous
close collaboration between dental and medi-
cal professionals are essential in providing
optimal periodontal and diabetic care.
104 Seshima F et al.
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Correspondence:
Dr. Atsushi Saito
Department of Periodontology,
Tokyo Dental College,
2-9-18 Misaki-cho, Chiyoda-ku,
Tokyo 101-0061, Japan
E-mail: atsaito@tdc.ac.jp