Introduction

Periodontal disease is a disease with an increasing number of associated risk factors

that have been identified in recent decades. Epidemiological studies have shown that risk
factors have been linked to disease progression [434, 439, 440]. The bacterial laque is the
initial, determining factor for the development of periodontal disease, but only the combined
effects of the various risk factors will ultimately lead to periodontal disease. These include:
plaque, supra and subgingival tartar, deficiencies in the quality of dental or prosthetic
restorations, smoking, edentination, malocclusions, traumatic occlusion, parafunctions, age,
gender, stress, obesity, systemic diseases and more [434, 441, 442, 443, 444].
Identification and management of risk factors have become a key component of
periodontal patient care [302, 434].
The aim of this study is to evaluate the causing and risk factors of periodontal disease
in the context of diabetic disease, in order to improve the prophylactic and therapeutic
approach to these pathologies.

7.3. Materials and method

The study was conducted on a number of 87 patients out of a total of 300 patients
treated between July 2018 and June 2019, the target population being non-diabetic, pre-
diabetic and diabetic patients.
The purpose of the research was explained to each patient, after which they signed a
consent to be part of the study.
Included in the group of patients are people: aged 18 and over; with full logical
thinking capacity; who expressed their agreement regarding the medical investigations
established by the study and regarding the completion of the proposed questionnaire; who
presented at least one adequate imaging investigation to allow the overall assessment of the
oral health status.
Exclusion criteria: patients who refused to be included in the research base, patients
who could not cooperate for medical reasons, minor patients
After obtaining the informed consent, the study participants completed a
questionnaire that evaluated all established risk factors for dysglycemia, namely: age, sex,
background, level of education (studies), occupation, history of vascular disease, history of
hypertension and the treatment followed for it, history of dyslipidemia and treatment, family
history of diabetes, personal history of diabetes, its type, age and treatment followed for the
disease.
Anthropometric measurements included height (measured in centimeters), weight
(measured in kilograms), body mass index (BMI - measured in kg/m2) was calculated. When
BMI ≥ 25kg/m2, the patient was considered overweight, and when BMI ≥ 30kg/m2, the
patient was considered obese.
Blood pressure was determined using a DS-11 electronic sphygmomanometer of
NISSEI, NIHON SEIMITSU SOKKI CO, LTD, Japan. Self-reported cholesterol and
triglyceride levels were noted. The existence of other medical conditions was also specified.
A capillary blood sample from the finger was used to determine the glucose level,
after the puncture site was disinfected with alcohol by swabbing, allowed to dry, and then
punctured with a sterile disposable lancet, placing a drop of blood on the strip glucose
monitoring device test [297, 298, 299]. The glucometer used in the study was the Accu-Chek
Sensor (Roche Diagnostic, Germany), which works on the enzyme electrode principle. The
system consists of a meter and dry reagent test strips designed for capillary blood glucose
testing by people with diabetes or by healthcare professionals. Test strips are calibrated to
report plasma glucose values. Glucose in the blood sample mixes with the enzyme on the test
strip and turns into gluconolactone which generates an electrical charge. The strength of these
charges changes with the amount of glucose. Electrodes built into the test strip measure the
charge and give a digital reading [300]. The test strip is inserted into the test hole of the
glucometer. A flashing falling symbol appears on the monitor, suggesting that the device is
ready for use. The yellow window of the test strip must be completely filled with blood
within a maximum of 15 seconds. The result is provided in 26 seconds [300]. The value was
considered normal if it was < 100mg/dl. It was considered prediabetes if the value was
between 100 - 125mg/dl and diabetes if it was ≥ 126mg/dl [301]. Subjects with abnormal
values were directed to seek further medical evaluation.
All study participants benefited from a complete exooral and endooral clinical
examination (including the periodontal record), performed by inspection, palpation,
percussion, auscultation.
The evaluation included the following clinical parameters: present teeth, missing
teeth, teeth with simple and complicated odontal conditions, teeth with correct/incorrect
odontal restorations, mobile teeth, teeth with adequate/inadequate interproximal contacts,
edentulous gaps, improperly or partially prosthetic edentulous teeth inclined, in occlusal
trauma, bruxism.
 The following were recorded: presence or absence of bacterial plaque, supra and
subgingival tartar, mucogingival damage, presence or absence of gingival recession, loss of
clinical attachment, presence of periodontal pockets, bleeding or purulent secretion, furcation
damage. To highlight and quantify the bacterial plaque, the O'Leary plaque index was
determined, a qualitative and percentage index of its identification on the vestibular, oral,
mesial and distal dental surfaces.
The periodontal examination included the periodontal survey with the Wiliams
manual periodontal probe, determining the depth of the gingival sulcus, the presence of
gingivoragia, attachment loss and gingival retraction. The survey was carried out in 3
vestibular points and 3 oral points for each existing tooth, the survey value in each point
being noted on the periodontogram. Determination of the level of gingival attachment
assessed the stabilization or progression of periodontal tissue destruction. Probing depth was
measured (A1), the distance from the gingival margin to the enamel-cementum junction (A2)
was measured, and the level of gingival attachment was the difference (A1-A2) [303].
In this study, periodontal disease was diagnosed according to the criteria of the
Centers for Disease Control and Prevention in partnership with the American Association of
Periodontology [445]. Patients presenting periodontal pockets in 2 or more interproximal
points, with a gingival attachment level ≥ 3mm, with probing depths ≥ 4mm in two or more
interproximal points (for different teeth), or periodontal pockets ≥ 5mm, in a single point,
have been diagnosed with this condition. The level of clinical attachment was measured only
when a pouch ≥3mm was found in a single interproximal point.
The percentage of bone loss was estimated from the examination of the
orthopantomogram. Subjects were classified as having mild bone loss if more than 30% of
teeth had < 15% bone loss, while advanced bone loss was defined as ≥ 15% bone loss in
more than 30% of teeth . Also, subjects with gingival attachment level ≥ 3mm on more than
30% of teeth were classified as having severe periodontal disease.
All personal data collected were subject to the confidentiality regime provided by
Romanian legislation in force, the published data were only statistical, personal data were not
included in the result. All collected data is kept at C.M.I. Dr. Iova Gilda.
The methods used and the statistical processing of the data correspond to those
described in Personal Contributions, subsection 2.2. and the Annex "Questionnaire -
Questions about health status knowledge and dentist involvement in diabetes screening".