A study to determine the interrelationship between diabetes and gum disease
- Conditions
- PATIENTS SUFFERING FROM TYPE 2 DIABETES MELLITUS AND PERIODONTITIS
- Registration Number
- CTRI/2014/08/004849
- Lead Sponsor
- Dr r AHMED DENTAL COLLEGE
- Brief Summary
Thepresent study was conducted for the better understanding of the relationshipbetween type 2 diabetes mellitus and chronic periodontitis as well as toinvestigate the effect of periodontal therapy in subjects with type 2 diabetesmellitus with chronic periodontitis in the absence of any changes in themedical therapy during the study period. At baseline, both the treatment andthe control group showed similar levels of plaque accumulation, gingival andperiodontal inflammation, as well as of periodontal breakdown (PPD, CAL).
Theresults of the present study demonstrated a significant improvement ofmetabolic control in the subjects of treatment group (Group A) at 3 months posttherapy. A statistically significant decrease in HbA1c level (0.82%) was observedin the treatment group. Similar observations were made by **Kiran** **et al**.;they examined the effect ofperiodontal therapy with systemic doxycycline on periodontal health andglycemic control of individual type 2 DM subjects.
Theyhad a control group of patients with diabetes whose periodontal status wassimilar and received no treatment as seen in the present study. Improvement ofglycemic control with a reduction in mean HbA1c value (0.8%) was reported to bestatistically significant. Control group of subjects in the present studyshowed negligible increase in HbA1c value after 3 months while in **Kiran’s Study**, there was no change.
**Iwamotoet al***.*reported aslight reduction in plasma HbA1c level (0.8%) in a group of 13 Japanesesubjects with type 2 DM. **Grossi et al***.*conducted a researchinvolving type 2 DM subjects with severe periodontitis and treated them withSRP , subgingival irrigation (H2O, Chlorhexidine, povidone I2plus placebo or doxycycline- 100mg daily for 14 days). They reported significantreduction in HbA1c levels in subjects receiving doxycycline compared to placebotreated group which did not reach significance. Similar results were obtainedby **Stewart et al**.Theseobservations were in accordance with the present study.
**Rodrigueset al***.* also reported similar statistically significant reduction in HbA1c level afterperiodontal therapy in type 2 DM patients with chronic periodontitis, butinstead of doxycycline, they used amoxicillin/clavulanic acid-875mg as anadjunct to mechanical debridement. Similar observations were made by **Singh et al***.* but they used systemic doxycycline as an adjunct tomechanical debridement. We used adjunctive systemic doxycycline 100mg for 14days in our study along with scaling and root planing based on the study by **Grossi et al**. and itsusage can be justified by the following:
First, it is abroad spectrum antibiotic that is effective against most of the periodontalpathogens and it reaches higher concentration in GCF than in serum, providingan important adjunct for the reduction of periodontal pathogens.
Secondly it is apotent modulator of the host response in the subject with diabetes, as well asbeing a metalloproteinase inhibitor. It also inhibits non-enzymatic glycationof extracellular proteins, and it may have a similar effect on the glycation ofhemoglobin. When amoxicillin with clavulanic acid was used as anadjunct to periodontal therapy, no additional effect on the HbA1c levels wasobserved.
**Promsudthi et al**.reported a reduction in HbA1c levelafter periodontal therapy, but contrary to other studies, this decrease was notstatistically significant. Similarly **Daget al**.alsoobserved a non significant decrease in HbA1c values after periodontal therapy.
Mostof the studies done previously incorporated non diabetic patients as controlgroup and hence could not make a definitive conclusion; therefore to determinethe relative contribution of periodontal therapy in glycemic control, thepresent study was designed to include type 2 DM subjects with chronicperiodontitis as control group that did not receive any periodontal treatmentduring the study period.
Incontrast to the findings in the present study, **Christgau et al**. reported that periodontal therapydid not affect the levels of HbA1c in uncontrolled diabetic subjects (i.e.HbA1c > 7%). **Westfelt et al**. also claimed that HbA1c levels did not change with mechanical periodontaltherapy. Similar results were obtained by **Seppalaet al**.and **Patricia etal**.Current researches indicated lack of consensus as towhether non surgical therapy contributed to better glycemic control.
The healing results of the periodontaltherapy were assessed after 3 months. There are contradictory opinions in theliterature concerning the appropriate time for assessing the healing responseto periodontal therapy. **Morrison et al**.in 1980 and **Lowenguth and Greenstein**in 1995 suggested a period of one month. **Baderstenet al**. in 1981 found that in periodontal pockets of 4-7 mm depth, mostchanges occur in the first 4-5 months while the deep pockets up to 12mm, agradual improvement takes place over a period of 12 months. In ourstudy, since the mean probing depth of most of the subjects was around 3mm, theresponse to periodontal therapy was evaluated after 3 months.
Mechanicalscaling and root planing is very essential for removal of plaque and calculusfor reduction of inflammation as type 2 diabetics have an increasedsusceptibility to inflammation. Hence, the therapy led to a 71.2%reduction in the mean gingival index, 32.6% reduction in the mean probingpocket depth and 11.7% gain in the mean clinical attachment in the presentstudy. Theseimprovements were reflected at the systemic level by alterations in the serumTNF-α as well as reduction in glycated hemoglobin.
Numerous studies havereported the favorable effect of nonsurgical periodontal treatment onperiodontal healing as well as an improved glycemic control among Type 2diabetic patients.
Ithas been generally believed that periodontal infection related TNF-αcontributes to systemic inflammatory reaction. TNF-α is believed to be releasedfrom adipocytes and to cause insulin resistance together with obesity.Researchers have also suggested that TNF-α impairs insulin signaling byincreasing the adiposity secretion of free fatty acids.Researchers now agree that this process strengthens glycemic control by raisinginsulin resistance in diabetic patients and this hypothesis suggests thatperiodontal therapy can effectively improve glycemic control by decreasingproinflammatory mediators. However, there is no consensus still among theresearchers as to whether periodontal therapy has an effect on inflammatorymediators and glycemic control.
**Yang et al**. found a significant reduction in serum TNF-α, HbA1c and periodontal parametersfollowing periodontal therapy in the treatment group consisting of type 2 DMpatients with chronic periodontitis. They suggested that periodontal therapycould effectively reduce HbA1c levels by reducing circulatory TNF-αconcentration. Similar observations were made by **Iwamoto et al**. and **Dag et al**.
Severalworkers claimed that the achieved reduction of TNF-α level in circulation wasin response to systemic doxycycline which caused a decrease I periodontalinfection and inflammation. It appears difficult to establish the role of nonsurgical periodontal therapy alone in respect to glycemic control, it mighthowever be mentioned that many factors influenced the short term glucose leveland one of these factors was medical care.
In the present study, a significant decreasein TNF-α level (10.98±3.63 at baseline to 7.85±2.46) was obtained in thetreatment group (**Group A**) inaccordance to the above mentioned studies. In contrast to the above findings, **Kardesxler et al**. and **Yamazaki et al**. reportedthat increased TNF-α was associated with inflammatory periodontal disease, butsignificant post treatment reduction in TNF-α was not observed by them.
However, **Talbert et al**.reported an increase in TNF-α levelafter periodontal treatment. **Nishimuraet al**. suggested that periodontitis raised serum TNF-α leveland affected insulin resistance. In agreement with this suggestion, thedetermination of positive correlation between TNF-α and probing pocket depth(PPD) and TNF-α and gingival index (GI) in this study were compatible showing acorrelation between TNF-α and periodontitis.
Serums TNF-αvalues were correlated with HbA1c as well as with the periodontal parameters inthe present study (i.e. GI, PPD & CAL). A positive correlation was foundbetween them and hence this study supports the hypothesis that the betterglycemic control obtained after periodontal treatment in the treatment groupwas due to reduction of gingival index and bleeding on probing brought about byreduction in the inflammatory mediators, including TNF-α. Reduction in all theclinical parameters in the present study supported the observation of **Engebretson et al**. whoclaimed a positive correlation between TNF-α and clinical attachment levels and**Bretz et al**. whoshowed correlation between TNF-α and severe periodontitis.
Although thefasting blood glucose level is not a good indicator of glycemic control as itis susceptible to great oscillations, the treatment group showed astatistically significant reduction in its level after 3 months in thetreatment group. In order to standardize the results obtained in the study, nochange in the medication or diet was made for the patients. None of thepatients received any additional guidance in managing their diabetic status.
The mainlimitation of our study was the small number of patients incorporated withinthe study and a small follow up period. The follow up period could not beextended as the control groups of patients were also diabetics with chronicperiodontitis, and hence it would have been ethically unacceptable to deferperiodontal treatment in these patients for a longer period. Also thepossibility that the observed improvements in glycemic control and in thereduction of serum TNF-α might be due to diet, was not controlled in our study.
This was arandomized control trial done to evaluate the effect of non surgical therapy onperiodontal health and glycemic control in type 2 diabetics. The fact thatTNF-α decreased after 3 months and that clinical and metabolic improvementswere demonstrated following periodontal therapy, it can be safely said that itis a strong indicator of systemic health amelioration.
Non surgicalperiodontal therapy with adjunctive doxycycline significantly reduces thebacterial load in the biofilm which subsequently reduces the release ofproinflammatory mediators including TNF-α. The reduced levels of inflammatorymediators lead to attenuated periodontal tissue damage on one hand and in turn,which on the other hand improves glycemic control. This, in turn attenuates theinflammatory process in the periodontal tissues by regulating chemokineproduction.
Effectivecontrol of the inflammatory process by reduction of the pathogenic bacteria aswell as the diabetic condition provide a favorable periodontal tissueenvironment that allows tissue repair reflected by the clinical improvementsobserved in the study.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Completed
- Sex
- All
- Target Recruitment
- 30
- •Patients > 30 years, both males and females.
- •Chronic generalized periodontitis patients •Patients diagnosed with type 2 diabetes mellitus (HbA1c 7-10%) •No major diabetic complications.
- •Patient willing to take part in the study and maintain appointment regularly.
- •Patients suffering from any other systemic diseases.
- •Present and past smokers.
- •Patients who have undergone periodontal treatment 6 months prior to the study.
- •Pregnant or lactating mothers.
- •Patients who have received any antibiotics for the last three months.
- •Less than 16 remaining natural teeth.
Study & Design
- Study Type
- Interventional
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method STATISTICALLY SIGNIFICANT REDUCTION IN SERUM TNF-ALPHA AND GLYCATED HAEMOGLOBIN AFTER PERIODONTAL TREATMENT 3 MONTHS
- Secondary Outcome Measures
Name Time Method statistically significant reduction in clinical periodontal parameters after treatment namely, probing pocket depth (PPD), clinical attachment level (CAL), gingival and plaque index 3 months
Trial Locations
- Locations (1)
Dr R AHMED DENTAL COLLEGE
🇮🇳Kolkata, WEST BENGAL, India
Dr R AHMED DENTAL COLLEGE🇮🇳Kolkata, WEST BENGAL, IndiaDr MANOJ KUMARPrincipal investigator9937255588dr_mks121@yahoo.co.in