CASE REPORT

Maturity Onset Diabetes of the Young and Generalized Stage III Grade C
Periodontitis: A Case Report
Ren Jie Jacob Chew∗ and Hoe Kit Chee†

Introduction: Maturity onset diabetes of the young (MODY) is a rare form of diabetes mellitus resulting from single
nucleotide polymorphisms. There is a lack of evidence describing their periodontal condition and the management of these
patients. The objective of this case report is to present the 6-month outcomes following non-surgical periodontal treatment
of a patient diagnosed with MODY 5, the Renal Cyst and Diabetes Syndrome.
Case Presentation: This case report describes the periodontal presentation and non-surgical management of a
21-year-old patient, diagnosed with hyperglycemia (HbA1c >14%) and stage 4 chronic kidney disease. She presented with
generalized severe chronic periodontitis and multiple periodontal abscesses. She was treated with quadrant debridement
with adjunctive systemic amoxicillin and metronidazole and 0.2% chlorhexidine mouth rinse. Significant improvement was
observed after treatment, remaining stable 6-month post-treatment, with only two sites with probing depths 5 mm. This
was consistent with a reduction of the periodontal inflamed surface area from 3165 to 500 mm2 . HbA1c was also reduced
to 8.7% 6 months after treatment.
Conclusions: MODY patients presenting with periodontitis can be successfully treated non-surgically, concurrent
with diabetic management. Clin Adv Periodontics 2020;0:1–6.
Key Words: Anti-bacterial agents; dental scaling; diabetes mellitus; genetic predisposition to disease; periodontitis.

Background for periodontitis.2 Emerging evidence also suggests that it

Diabetes mellitus (DM) and periodontitis have a two-way
relationship best described as a “vicious cycle”.1 Hyper-
glycemia and its downstream effects on the host immune-
inflammatory response increases the host susceptibility
∗ Discipline
of Periodontics, Faculty of Dentistry, National University of
Singapore, Singapore
† Periodontics Unit, Department of Restorative Dentistry, National Den-
tal Centre Singapore, Singapore
Received January 20, 2020; accepted June 14, 2020
doi: 10.1002/cap.10114
promotes dysbiosis of the periodontal microbiome.3 Poor
glycemic control influences the severity and progression of
periodontitis, periodontal stability, and ultimately tooth
loss.4 The majority of the available literature is focused
on type 2 DM with less evidence pertaining to uncommon
forms of DM.5
A rare presentation is maturity onset diabetes of the
young (MODY), which is a group of monogenic disorders
that is hereditary and typically diagnosed in adolescence
or young adulthood.6 MODY results from genetic muta-
tions that disrupt insulin production. At least 14 gene
mutations have been identified, each resulting in a MODY
subtype with varying clinical presentation and severity,

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FIGURE 1 Baseline periodontal charting (July 11, 2018).

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A such as mild fasting hyperglycemia

to severe diabetes and many other
complications.7 Therefore, the
management also depends on the
specific MODY subtype and can
range from lifestyle changes and oral
antidiabetic medication to insulin
therapy.8 MODY 5 results from a
mutation in the hepatocyte nuclear
factor-1β and presents with pancreatic
atrophy and renal cysts. It is also
known as renal cyst and diabetes
syndrome.9 Severe periodontitis may
exacerbate the renal condition by
contributing additional inflammatory
stimulus and oxidative stress.10
B Little is known on the periodontal
condition of individuals having MODY.
To the best of our knowledge, this
is the first case reported on the
periodontal condition and non-surgical
management of a young adult patient
diagnosed with MODY 5.

Clinical Presentation
FIGURE 2 Patient’s radiographic records. 2aOrthopantomogram (July 11, 2018); 2bPeriapical A 21-year-old Singaporean Chinese
radiographs (July 11, 2018).
female was referred to the National
Dental Centre of Singapore on July
A 11, 2018, complaining of halitosis,
and swollen and painful gums. A
written informed consent form for
treatment was signed by the patient
on the same date. She was previously
diagnosed with MODY 5 in 2007 and
has a history of poor compliance with
insulin. Due to the presence of renal
cysts, she has stage 4 chronic kidney
disease. In addition, she presented with
gout, secondary to hyperuricemia. She
is a non-smoker and a non-drinker.
Owing to dental phobia as a child, she
was an irregular dental attendee.
Intraoral examination revealed poor
oral hygiene, with gross hard and soft
deposits. The periodontium was gen-
B C erally inflamed, with marked edema
and friable consistency. Tooth #6, #7,
#14, #23, and #29a presented with
periodontal abscesses. Detailed base-
line periodontal parameters are shown
in Figure 1. Radiographic bone loss
was irregular, and most severe on the
lower incisors, involving the apex of
#23a (Fig. 2). Her dentition presented
FIGURE 3 Pre-treatment intra-oral photographs. 3a Frontal view; 3b Maxillary occlusal view; 3c with generalized severe dental fluo-
Mandibular occlusal view. rosis, without active caries (Fig. 3).

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FIGURE 4 Post-treatment periodontal charting (March 29, 2019).

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A Discussion
This case report illustrates a case of
severe periodontitis with multiple
periodontal abscesses in a young
adult patient with MODY 5. MODY
represents a rare and unique form of
DM with underlying genetic etiology.
To date, there is a lack of evidence
regarding periodontitis prevalence,
progression, and clinical presentation
in patients with MODY. As there are
numerous forms of MODY, each with
a differing allele/gene, with varying
severities, the heterogeneity would make
it difficult to assemble enough cases for
longitudinal studies. While periodontitis
is modified by hyperglycemia, the lack
B C of a unique disease phenotype excludes
it from the diagnosis of periodontitis as
a manifestation of systemic disease.13
While some have proposed that people
with poorly controlled diabetes were
more prone to periodontal abscesses,
this was not well substantiated in the
literature.
This reported case of severe
FIGURE 5 Post-treatment intra-oral photographs. 5a Frontal view; 5b Maxillary occlusal view; 5c periodontal disease cannot be attributed
Mandibular occlusal view.
solely to the proinflammatory host
response alone, given the abundant supra- and subgingival
Periodontally, she was diagnosed as having generalized
microbial deposits that were present. Once removed,
moderate-to-severe chronic periodontitis with multiple
there was significant disease resolution. Adjunctive
periodontal abscesses. With the new classification of
systemic antibiotics with chlorhexidine mouth rinse
periodontal diseases, this would be generalized Stage III
11 were used to suppress the periodontal pathogens.14
Grade C periodontitis.
The latter also compensated for the suboptimal oral
hygiene. Improvement in the patient’s periodontal
Case Management health was accompanied by improvement in glycemic
The patient was managed with non-surgical periodontal control. This could be attributed to both improved
therapy and adjunctive antimicrobials. Quadrant root adherence to insulin and the reduction in PISA. Given
surface debridement consisting of thorough ultrasonic the bidirectional relationship between periodontitis
scaling and root planing under local anesthesia was per- and DM, co-management between the dentist and
formed over four visits within 1 week. At the fourth visit, endocrinologist would be critical.15 While the patient’s
systemic antibiotics were prescribed, consisting of amox- glycemic control remained suboptimal (>8%), it
icillin 500 mg and metronidazole 500 mg, BD for 7 days, did not impede the improvement from non-surgical
given the declining renal function. Twice daily rinsing treatment.16 Periodontal therapy should not be
with 10 mL of 0.2% chlorhexidine was prescribed for
3 months. Her #23‡ exfoliated during periodontal treat-
ment and was replaced with a resin-bonded provisional.
TABLE 1 Changes in key dental and periodontal parameters

Clinical outcomes
6 months
Upon completion of initial periodontal therapy, the peri- Baseline post-treatment
odontal inflamed surface area (PISA)12 was reduced
Number of teeth 28 27
markedly and the patient’s HbA1c decreased from >14%
to 8.7%. The 6-month post-treatment periodontal con- Number of sites with 107 2
dition is shown in Figures 4 and 5. Changes in the key probing depth 5 mm
parameters are listed in Table 1. Consequently, the patient Full mouth bleeding score 100% 39%
was placed on 3-month supportive periodontal therapy. 2
Periodontal inflamed 3,165 mm 500 mm2
‡ American
surface area12
Dental Association Universal Numbering System

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withheld until glycemic control is achieved. It should
be part of the holistic management of patients with
diabetes.
For long-term stability, personalized supportive peri-
odontal therapy is critical.17 While the patient demon-
strated marked improvement, optimal levels for both oral
hygiene and glycemic control were not achieved, there-
fore she was placed on a stringent 3-month maintenance
program. Longitudinal studies on periodontally treated
patients with diabetes highlight the importance of adher-
Summary
Why is this case new  Novel case of generalized severe chronic periodontitis/periodontitis
information? Stage III Grade C modified by diabetes of a genetic origin in a young
patient.
What are the keys to successful  Adequate mechanical and chemical plaque control
management of this case?  Improvement of patient compliance to insulin therapy
What are the primary limitations  Stability of outcomes are dependent on patient adherence to both
to success in this case? hygiene, supportive periodontal therapy, and insulin.
Acknowledgments
The authors also declare that they did not receive any
financial support for this case report. The authors report
no conflicts of interest related to this case report.
Author Contributions
The authors contributed equally to the preparation of
this case report, including the photographs and clinical
charts. The management of the case is by the authors,
Dr Chew Ren Jie Jacob (initial periodontal treatment
and post-instrumentation reviews) and Dr Chee Hoe Kit
(periodontal maintenance)
CORRESPONDENCE
Dr Chee Hoe Kit, Periodontics Unit, Department of Restorative
Dentistry, National Dental Centre Singapore, Singapore. E-mail:
chee.hoe.kit@singhealth.com.sg
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6 Clinical Advances in Periodontics, Vol. 0, No. 0, xxxx 2020
ence to individualized supportive care and address the
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MODY presents early in life and increases the risk of
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betes and periodontal disease, screening for periodontitis
and its treatment will be beneficial for the patient’s oral
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Maturity Onset Diabetes of the Young and Generalized Stage III Grade C Periodontitis