GINGIVAL INFLAMMATION AS A SIGN OF DIABETIC SYSTEMIC CHRONIC COMPLICATIONS
recognized as one of the complications of DM 4-8. What is less clear is the impact of periodontal disease on glycemic control of DM and the mechanisms through which this occurs. Some authors suggest that an intensive gingival inflammation relate to poor glycemic control and multiple diabetic complications 7-11. Periodontal disease may be more frequent and severe in diabetic individuals with more systemic complications. The evidence suggests that mechanisms which account for the development of systemic diabetic complications might also be crucial in the pathogenesis of increased periodontal destruction in DM 12, 13. The diabetic state impairs the synthesis of collagen and glycosaminoglycan, enhances crevicular fluid collagenolytic activity which lead to the loss of periodontal fibres and loss of the alveolar supporting bone 14, 15. This predisposes to chronic inflammation, progressive tissue breakdown and diminished tissue repair capacity. These mechanisms cause periodontal tissue breakdown and loosening of the teeth 14-16. The increased activity of periodontal disease in diabetic patients does not correlate with levels of plaque and calculus which do not have higher values in diabetic patients. Collectively, the evidence supports the theory that there is a relationship between the two diseases, especially in patients with poorly controlled DM 17. This proposed dual pathway of tissue destruction suggests that control of DM is necessary for achieving long-term control of periodontal disease 7-11.
2. The aim of the study The aim of the study was to analyze periodontal health in patients with diabetes mellitus type 2 related to diabetic complications and HbA1c values.
3. Methodology 3.1. Study design and subjects This clinical study was carried out as a joint collaboration between Department of Endocrinology and Department of Periodontology and Oral medicine, Niš University, Faculty of Medicine. The study protocol was reviewed and approved by the Niš University Faculty of Medicine Institutional Ethical Committee( identification number 01-2800-7) and in accordance with the Helsinki Declaration of 1975, as revised in 2000. 3.2. Subjects Patients with periodontitis and DM were selected from the pool of followed patients at the Department of Endocrinology, Niš University Medical Center. After the patient history was taken, patients who had acute systemic or oral disease, autoimmune diseases, hemorrhagic disorders, who had undergone antibiotic and corticosteroid therapy in the last three months, as well as patients who had periodontal treatment in the last three months were not included in the study. One hundred patients with periodontal disease and type 2 DM, 48( 48 %) women and 52( 52 %) men, the mean age 62.57 ± 8.57 years participated in the study. The HbA1c level was taken from the patient records. In the analysis according to the HbA1c values patients were divided in four groups: group 1( 4 %-6 % HbA1c; normal metabolic control), group 2( 6.1 %-7 % HbA1c; good metabolic control), group 3( 7.1 %-8 % HbA1c; moderate poor metabolic control), group 4(> 8 % HbA1c; poor metabolic control). The presence of chronic systemic microvascular diabetic complications( retinopathy, nephropathy and neuropathy) was recorded from patients records, and according to presence of these complications patients were divided in groups: patients with chronic systemic DM complications( group A) and patients without chronic systemic DM complications( group B). 3.3. Oral examination protocol The periodontal assessments were performed by a single examiner on four sites per tooth( mesiobuccal, disto-buccal, mesio-lingual, disto-lingual) for all( third molars excluded) fully erupted permanent teeth, using a manual periodontal probe. Using the tip of the periodontal probe inserted into the pocket with constant probing force the following were evaluated: Plaque index( PI) 18, Gingival Index( GI) 19, Calculus index( Cal) 20, and Periodontal Disease Index( PDI) 21. Afterwards, all of the patients received oral hygiene instructions and full-mouth scaling and root planning. 3.4. Diabetes-related variables The following information were collected from medical records: sex, duration of DM( years since diagnosis) and patient age. For the metabolic assessment, the HbA1c level was calculated from the patient records. 3.5. Analytical methods The statistical analysis was performed using SPSS software program and parameters were shown as mean values( X) and standard deviations( SD). Student t-test, Leven method, Tukey HSD test and Dunnett T3 test were used for analysis of statistically important difference between mean values of two groups. The results are shown tabularly using MS Office Excel, program SPSS, 15.0 version.
4. Results The study population included patients with DM type 2 aged 22-83 years, 51 women and 49 men. Mean HbA1c value was 8. 70 ± 0. 45 % and the mean DM duration 14.68 ± 3.43 years. Comparing mean values and standard deviations( X ± SD) of PI, Izk, Ikon, Gi and PDI indexes according to HbA1c values, ANOVA analysis showed that Gi values depended on the level of HbA1c values( p < 0,001). Higher values of investigated indexes were noticed as the value of HbA1c was rising( p < 0,001)( Table 1). Comparing mean values and standard deviations( X ± SD) of PI, Izk, Ikon, Gi and PDI indexes according to presence of chronic systemic DM complications, it was noticed that only Gi values were higher in the group with chronic systemic DM complications( retinopathy, nephropathy and neuropathy)( t = 5.42, p < 0.001)( Table 2).
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