ORIGINAL Muthu ARTICLE et al
Effect of Nonsurgical Periodontal Therapy on the Glycaemic Control of Nondiabetic Periodontitis Patients: A Clinical Biochemical Study Jananni Muthua/Sivaramakrishnan Muthanandamb/Jaideep Mahendrac/ Ambalavanan Namasivayamd/Libby Johne/Anitha Logaranjinif Purpose: To compare the HbA1c levels in nondiabetic subjects with periodontitis and periodontally healthy controls and to evaluate the effect of nonsurgical periodontal therapy on the glycaemic control in nondiabetic subjects with periodontitis. Materials and Methods: A total of 220 nondiabetic subjects between 35 and 60 years old were selected and divided into two groups: group A (case group), comprised of subjects with chronic periodontitis, and group B (control group), comprised of subjects with healthy periodontium. Periodontal clinical parameters (plaque index, modified sulcular bleeding index, probing depth and clinical attachment level) were used to assign the subjects into the respective groups. The HbA1c level was estimated for both groups using a commercially available kit. Subjects in group A underwent nonsurgical periodontal therapy in two to four sessions along with oral hygiene instructions. The periodontal parameters and HbA1c levels were again evaluated in the test group three months following periodontal therapy. Results: The HbA1c levels were higher in the case group (A) than the control group (B). Three months following periodontal therapy in group A, there was improvement in periodontal parameters. The HbA1c levels decreased signifi cantly from baseline to 3 months. Conclusion: The results of this study found chronic periodontitis to be associated with a significant increase in glycosylated haemoglobin levels in nondiabetic periodontitis subjects. Furthermore, with improvement of periodontal status, the glycaemic levels return to near normal values. Key words: chronic periodontitis, diabetes mellitus, glycosylated haemoglobin, HbA1c%, nonsurgical periodontal therapy, prediabetic state Oral Health Prev Dent 2015;13:261-266 doi: 10.3290/j.ohpd.a32995
a
Senior Lecturer, Department of Periodontology and Implantology, Indira Gandhi Institute of Dental Sciences, Pondicherry, India. Idea, hypothesis, experimental design, performed the experiments in partial fulfillment of requirements for a degree, wrote the manuscript. b Senior Lecturer, Department of Oral Pathology and Microbiology, Indira Gandhi Institute of Dental Sciences, Pondicherry, India. Proofread manuscript. c Professor, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Contributed substantially to discussion. d Professor and Head, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Hypothesis, contributed substantially to discussion. e Senior Lecturer, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Contributed substantially to discussion. f Senior Lecturer, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Proofread manuscript. Correspondence: Dr. Jananni Muthu, Dept. of Periodontics, Indira Gandhi Institute of Dental Sciences, Pondicherry, 607402. India. Tel: +91-098-4245-5402. Email: [email protected]
Vol 13, No 3, 2015
Submitted for publication: 14.03.13; accepted for publication: 26.08.13
T
he understanding of the aetiology and pathogenesis of periodontal diseases and their chronic, inflammatory and infectious nature suggests that these infections may influence events elsewhere in the body. At the same time, a consequence of recognising the interaction between oral diseases and some systemic conditions is that dentists and periodontists should direct their practice and knowledge not only to events strictly related to the oral cavity but also consider systemic conditions and diseases which may change or interfere with established preventive and therapeutic approaches.36 Poorly controlled diabetes is also a well-recognised risk factor for developing periodontal disease. Years of research have established a number of mechanisms by which diabetes can influence the periodontium.4 There is also evidence that
261
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periodontal disease can worsen a patient’s control of diabetes mellitus and that proper management of periodontal disease can improve control of diabetes mellitus.11 Intervention trials have assessed the results of periodontal therapy on glycaemic control in subjects with diabetes. Several studies of subjects with diabetes and periodontitis showed improvement in glycaemic control following nonsurgical periodontal treatment (scaling and root planing). This was also associated with a reduction in glycated haemoglobin levels.37 The presence of glycated haemoglobin in the circulation and tissues, resulting from the hyperglycaemia of diabetes, is believed to be a contributing factor to the degenerative microvascular and arterial changes that are a common sequel of diabetes.25 The purpose of this study was to estimate and compare the HbA1c levels in nondiabetic subjects with periodontitis and periodontally healthy controls and to evaluate the effect of nonsurgical periodontal therapy on the glycaemic control in nondiabetic subjects with periodontitis.
MATERIALS AND METHODS The subjects for this study were recruited from the patient pool of the Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, India. The ethical permission for the study was granted by the Meenakshi Institutional Review Board and all participants provided written informed consent. Subjects were recruited into the study based on the following criteria. The inclusion criteria were: patients between 35 and 65 years old, nondiabetic, had ≥ 10 natural teeth and no history of long term antibiotic use (≥ 14 days) in the past 6 months. Patients with conditions that shorten erythrocyte survival (haemolytic anaemia, pregnancy or recent signifi cant blood loss), smokers and patients who had undergone periodontal therapy within the previous 6 months37 were excluded from the study. A total of 220 (96 women and 124 men) nondiabetic subjects aged 35–50 years were recruited to this study and assigned to two groups based on the inclusion and exclusion criteria. Group A (case group; n = 130) consisted of chronic periodontitis cases, which were defined as those having 5 or more teeth with a probing depth (PD) ≥ 5 mm and a clinical attachment loss (CAL) > 3 mm or radiographic bone loss; a modified sulcus bleeding index (mSBI) score of ≥ 2 was considered as baseline
262
(mBI ≥ 2 in at least 15% of sites). Group B (control group, n = 90) included periodontally healthy participants with no probing depth (PD) greater than 4 mm, bleeding on probing (BOP) at ≤ 15% of tooth sites and no periodontal treatment (scaling, root planing or surgery) within the previous six months. All periodontal parameters were measured by a calibrated examiner using a William’s periodontal probe. The parameters recorded were plaque index (PI), modified sulcular bleeding index (mSBI), probing depth (PD) and clinical attachment level (CAL). The body mass index (BMI) was determined by dividing the body weight in kilograms by the square of the height in meters. The subjects were categorised as normal (BMI 18.5–24.9), overweight (BMI 25–29.9) and obese (BMI > 30). HbA1c assessment was done using a commercially available kit (Quantia HbA1c kit, Tulip laboratories; Verna, Goa, India). The HbA1c values were reported according to IFCC units.3 The reference range is as follows: nondiabetic 2.0 to 4.2; diabetic with good control 4.21 to 4.8; diabetic with fair control 4.81 to 6.4; diabetic with poor control > 6.5. All subjects in group A (cases) underwent nonsurgical periodontal therapy. Scaling and root planing were performed in 2–4 sessions for each individual using hand instruments and ultrasonic scalers while the subjects were under local anaesthesia (lignocaine 2% with 1:80,000 adrenaline). Three months after periodontal therapy, the periodontal parameters and HbA1c values were again measured in the case group. Only 75 of the treated cases reported back for the follow-up. Means and standard deviations were calculated for all clinical parameters and Hba1c values. The relationship between BMI and HbA1c levels was examined using Pearson’s correlation analysis. Student’s independent t-test was used to compare the two mean values from the control and the case group and Student’s dependent t-test or paired ttest was applied to compare the clinical parameters and the HbA1c levels in the case group at baseline and after 3 months.
RESULTS All periodontal parameters were higher in group A (case) than in group B (control). The HbA1c level at baseline was also significantly greater in the case group (3.84 ± 0.47) than the control group (2.26 ± 0.58) (p < 0.001) (Table 1).
Oral Health & Preventive Dentistry
Muthu et al
Table 1 Comparison of mean values of recorded clinical parameters, glycosylated haemoglobin levels and body mass index (BMI) between case and control groups at baseline Parameter
Group
Mean
SD
Case
1.90
0.60
Control
0.954
0.37
Case
2.34
0.41
Control
1.47
0.33
Case
5.86
0.81
Control
2.24
0.86
Case
3.40
0.58
Control
2.23
0.47
Case
23.97
0.23
Control
22.12
0.45
t-test value
PI
9.97
mSBI
PPD
HbA1c %
BMI
4
4 3.42
3.53
p-value < 0.001
12.94
< 0.001
22.92
< 0.001
11.64
< 0.001
7.32
0.97
4
3.49
3.40
2
0
2.32 2
HbA1c%
HbA1c%
HbA1%
3.01 2.06
0 normal overweight BMI
obese
2
0 normal
overweight
Baseline
3 months
BMI
Fig 1 Comparison of means of body mass index and HbA1c levels in case group.
Fig 2 Comparison of means of Body Mass Index and HbA1c levels in control group, p = 0.95.
Fig 3 Comparison of HbA1c levels in group B (test group) at baseline and after 3 months, p < 0.001.
Table 2 Comparison of means of periodontal parameters in case group at baseline and three months after periodontal therapy Baseline
3rd month
Parameter
Mean
SD
Mean
SD
Paired t-test value
p-value
PI
1.90
0.59
1.17
0.52
7.233
Effect of Nonsurgical Periodontal Therapy on the Glycaemic Control of Nondiabetic Periodontitis Patients: A Clinical Biochemical Study Jananni Muthua/Sivaramakrishnan Muthanandamb/Jaideep Mahendrac/ Ambalavanan Namasivayamd/Libby Johne/Anitha Logaranjinif Purpose: To compare the HbA1c levels in nondiabetic subjects with periodontitis and periodontally healthy controls and to evaluate the effect of nonsurgical periodontal therapy on the glycaemic control in nondiabetic subjects with periodontitis. Materials and Methods: A total of 220 nondiabetic subjects between 35 and 60 years old were selected and divided into two groups: group A (case group), comprised of subjects with chronic periodontitis, and group B (control group), comprised of subjects with healthy periodontium. Periodontal clinical parameters (plaque index, modified sulcular bleeding index, probing depth and clinical attachment level) were used to assign the subjects into the respective groups. The HbA1c level was estimated for both groups using a commercially available kit. Subjects in group A underwent nonsurgical periodontal therapy in two to four sessions along with oral hygiene instructions. The periodontal parameters and HbA1c levels were again evaluated in the test group three months following periodontal therapy. Results: The HbA1c levels were higher in the case group (A) than the control group (B). Three months following periodontal therapy in group A, there was improvement in periodontal parameters. The HbA1c levels decreased signifi cantly from baseline to 3 months. Conclusion: The results of this study found chronic periodontitis to be associated with a significant increase in glycosylated haemoglobin levels in nondiabetic periodontitis subjects. Furthermore, with improvement of periodontal status, the glycaemic levels return to near normal values. Key words: chronic periodontitis, diabetes mellitus, glycosylated haemoglobin, HbA1c%, nonsurgical periodontal therapy, prediabetic state Oral Health Prev Dent 2015;13:261-266 doi: 10.3290/j.ohpd.a32995
a
Senior Lecturer, Department of Periodontology and Implantology, Indira Gandhi Institute of Dental Sciences, Pondicherry, India. Idea, hypothesis, experimental design, performed the experiments in partial fulfillment of requirements for a degree, wrote the manuscript. b Senior Lecturer, Department of Oral Pathology and Microbiology, Indira Gandhi Institute of Dental Sciences, Pondicherry, India. Proofread manuscript. c Professor, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Contributed substantially to discussion. d Professor and Head, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Hypothesis, contributed substantially to discussion. e Senior Lecturer, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Contributed substantially to discussion. f Senior Lecturer, Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India. Proofread manuscript. Correspondence: Dr. Jananni Muthu, Dept. of Periodontics, Indira Gandhi Institute of Dental Sciences, Pondicherry, 607402. India. Tel: +91-098-4245-5402. Email: [email protected]
Vol 13, No 3, 2015
Submitted for publication: 14.03.13; accepted for publication: 26.08.13
T
he understanding of the aetiology and pathogenesis of periodontal diseases and their chronic, inflammatory and infectious nature suggests that these infections may influence events elsewhere in the body. At the same time, a consequence of recognising the interaction between oral diseases and some systemic conditions is that dentists and periodontists should direct their practice and knowledge not only to events strictly related to the oral cavity but also consider systemic conditions and diseases which may change or interfere with established preventive and therapeutic approaches.36 Poorly controlled diabetes is also a well-recognised risk factor for developing periodontal disease. Years of research have established a number of mechanisms by which diabetes can influence the periodontium.4 There is also evidence that
261
Muthu et al
periodontal disease can worsen a patient’s control of diabetes mellitus and that proper management of periodontal disease can improve control of diabetes mellitus.11 Intervention trials have assessed the results of periodontal therapy on glycaemic control in subjects with diabetes. Several studies of subjects with diabetes and periodontitis showed improvement in glycaemic control following nonsurgical periodontal treatment (scaling and root planing). This was also associated with a reduction in glycated haemoglobin levels.37 The presence of glycated haemoglobin in the circulation and tissues, resulting from the hyperglycaemia of diabetes, is believed to be a contributing factor to the degenerative microvascular and arterial changes that are a common sequel of diabetes.25 The purpose of this study was to estimate and compare the HbA1c levels in nondiabetic subjects with periodontitis and periodontally healthy controls and to evaluate the effect of nonsurgical periodontal therapy on the glycaemic control in nondiabetic subjects with periodontitis.
MATERIALS AND METHODS The subjects for this study were recruited from the patient pool of the Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, India. The ethical permission for the study was granted by the Meenakshi Institutional Review Board and all participants provided written informed consent. Subjects were recruited into the study based on the following criteria. The inclusion criteria were: patients between 35 and 65 years old, nondiabetic, had ≥ 10 natural teeth and no history of long term antibiotic use (≥ 14 days) in the past 6 months. Patients with conditions that shorten erythrocyte survival (haemolytic anaemia, pregnancy or recent signifi cant blood loss), smokers and patients who had undergone periodontal therapy within the previous 6 months37 were excluded from the study. A total of 220 (96 women and 124 men) nondiabetic subjects aged 35–50 years were recruited to this study and assigned to two groups based on the inclusion and exclusion criteria. Group A (case group; n = 130) consisted of chronic periodontitis cases, which were defined as those having 5 or more teeth with a probing depth (PD) ≥ 5 mm and a clinical attachment loss (CAL) > 3 mm or radiographic bone loss; a modified sulcus bleeding index (mSBI) score of ≥ 2 was considered as baseline
262
(mBI ≥ 2 in at least 15% of sites). Group B (control group, n = 90) included periodontally healthy participants with no probing depth (PD) greater than 4 mm, bleeding on probing (BOP) at ≤ 15% of tooth sites and no periodontal treatment (scaling, root planing or surgery) within the previous six months. All periodontal parameters were measured by a calibrated examiner using a William’s periodontal probe. The parameters recorded were plaque index (PI), modified sulcular bleeding index (mSBI), probing depth (PD) and clinical attachment level (CAL). The body mass index (BMI) was determined by dividing the body weight in kilograms by the square of the height in meters. The subjects were categorised as normal (BMI 18.5–24.9), overweight (BMI 25–29.9) and obese (BMI > 30). HbA1c assessment was done using a commercially available kit (Quantia HbA1c kit, Tulip laboratories; Verna, Goa, India). The HbA1c values were reported according to IFCC units.3 The reference range is as follows: nondiabetic 2.0 to 4.2; diabetic with good control 4.21 to 4.8; diabetic with fair control 4.81 to 6.4; diabetic with poor control > 6.5. All subjects in group A (cases) underwent nonsurgical periodontal therapy. Scaling and root planing were performed in 2–4 sessions for each individual using hand instruments and ultrasonic scalers while the subjects were under local anaesthesia (lignocaine 2% with 1:80,000 adrenaline). Three months after periodontal therapy, the periodontal parameters and HbA1c values were again measured in the case group. Only 75 of the treated cases reported back for the follow-up. Means and standard deviations were calculated for all clinical parameters and Hba1c values. The relationship between BMI and HbA1c levels was examined using Pearson’s correlation analysis. Student’s independent t-test was used to compare the two mean values from the control and the case group and Student’s dependent t-test or paired ttest was applied to compare the clinical parameters and the HbA1c levels in the case group at baseline and after 3 months.
RESULTS All periodontal parameters were higher in group A (case) than in group B (control). The HbA1c level at baseline was also significantly greater in the case group (3.84 ± 0.47) than the control group (2.26 ± 0.58) (p < 0.001) (Table 1).
Oral Health & Preventive Dentistry
Muthu et al
Table 1 Comparison of mean values of recorded clinical parameters, glycosylated haemoglobin levels and body mass index (BMI) between case and control groups at baseline Parameter
Group
Mean
SD
Case
1.90
0.60
Control
0.954
0.37
Case
2.34
0.41
Control
1.47
0.33
Case
5.86
0.81
Control
2.24
0.86
Case
3.40
0.58
Control
2.23
0.47
Case
23.97
0.23
Control
22.12
0.45
t-test value
PI
9.97
mSBI
PPD
HbA1c %
BMI
4
4 3.42
3.53
p-value < 0.001
12.94
< 0.001
22.92
< 0.001
11.64
< 0.001
7.32
0.97
4
3.49
3.40
2
0
2.32 2
HbA1c%
HbA1c%
HbA1%
3.01 2.06
0 normal overweight BMI
obese
2
0 normal
overweight
Baseline
3 months
BMI
Fig 1 Comparison of means of body mass index and HbA1c levels in case group.
Fig 2 Comparison of means of Body Mass Index and HbA1c levels in control group, p = 0.95.
Fig 3 Comparison of HbA1c levels in group B (test group) at baseline and after 3 months, p < 0.001.
Table 2 Comparison of means of periodontal parameters in case group at baseline and three months after periodontal therapy Baseline
3rd month
Parameter
Mean
SD
Mean
SD
Paired t-test value
p-value
PI
1.90
0.59
1.17
0.52
7.233
