|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
Periodontal disease and treatment needs among patients with diabetes mellitus Type 2 attending Talaga Bodas Community Health Center in Bandung City
Agus Susanto, Arina Sarah Amnani Manurung, Aldilla Miranda, Siti Sopiatin
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia
|Date of Submission||29-Aug-2019|
|Date of Acceptance||11-Jan-2020|
|Date of Web Publication||7-Feb-2020|
Dr. Agus Susanto
Jl. Raya Bandung Sumedang KM.21, Jatinangor, Sumedang, Jawa Barat 45363
Source of Support: None, Conflict of Interest: None
Background: Periodontitis has been referred to as the sixth complication of diabetes. A number of studies found a higher prevalence of periodontal disease among diabetes patients than among healthy controls. Objective: The objective of the study was to determine the periodontal status and periodontal treatment needs (TN) of diabetes mellitus Type 2 patients attending Talaga Bodas Community Health Center, Bandung City, Indonesia. Methods: This descriptive study included 30 subjects with diabetes mellitus Type 2. The periodontal tissue status and periodontal TN were determined using the Community Periodontal Index of TN. Data on periodontal status and TN are presented in percentages based on subject, sextant, and duration of diabetes mellitus. Results: Periodontitis (53.3%) was more common than gingivitis (43.3%) among diabetes mellitus Type 2 patients. Scaling and root planing were the treatments most commonly required in the diabetes mellitus patients (n = 21.70%) and sextants (n = 81.65.9%). A longer period of diabetes mellitus was associated with a tendency toward more severe periodontal disease and more complex periodontal TN. Conclusion: The prevalence of periodontitis was higher than gingivitis among patients with diabetes mellitus Type 2. The TN of diabetes mellitus Type 2 patients comprised mostly scaling and root planing.
Keywords: Community periodontal index of treatment needs, diabetes mellitus, oral health, periodontal disease
|How to cite this article:|
Susanto A, Manurung AS, Miranda A, Sopiatin S. Periodontal disease and treatment needs among patients with diabetes mellitus Type 2 attending Talaga Bodas Community Health Center in Bandung City. Sci Dent J 2020;4:1-5
|How to cite this URL:|
Susanto A, Manurung AS, Miranda A, Sopiatin S. Periodontal disease and treatment needs among patients with diabetes mellitus Type 2 attending Talaga Bodas Community Health Center in Bandung City. Sci Dent J [serial online] 2020 [cited 2022 Dec 7];4:1-5. Available from: https://www.scidentj.com/text.asp?2020/4/1/1/277873
| Background|| |
The prevalence of a periodontal disease among all age groups in Indonesia is high (96.58%). Periodontal disease is inflammation of the structures that support the teeth: gingiva, periodontal ligament, and alveolar bone. There are two main categories of periodontal disease, namely gingivitis and chronic periodontitis. Gingivitis is inflammation that is limited only to the gingiva, with supporting tissues unaffected., Periodontitis is inflammation that extends to the deeper tissues that support the teeth. It is characterized by gingival inflammation, loss of attachment, and progressive damage to periodontal ligaments and alveolar bone. Severe periodontal disease causes teeth to become mobile and requires tooth extraction.
Diabetes currently ranks fourth as a cause of death in most developed countries and has reached epidemic proportions in many developing countries. Diabetes is a metabolic disorder characterized by hyperglycemia, which results in damage to the insulin secretion system, the actions of insulin, or both. Diabetes is divided into four types: Type 1 diabetes, Type 2 diabetes, gestational diabetes mellitus, and diabetes other causes. Type 2 diabetes mellitus, or noninsulin-dependent diabetes, accounts for 90%–95% of all cases of diabetes. Individuals with Type 2 diabetes mellitus have insulin resistance and usually insulin deficiency.
Many clinical and epidemiological studies have demonstrated a relationship between diabetes mellitus and periodontal disease., The relationship between diabetes mellitus and periodontal disease is not entirely clear, possibly due to their complex nature. In a previous study, researchers reported a higher incidence and severity of periodontal disease in Type 2 diabetic patients as compared with that in nondiabetic controls.
Talaga Bodas Community Health Center was one of the first community health centers (Puskesmas) to be set up in Bandung, Indonesia. It is easily accessible and has a chronic disease management program (PROLANIS) that includes diabetes mellitus and hypertension. Since the opening of the center, many people have received treatment for diabetes mellitus. However, the periodontal disease status of these patients has never been reported. The purpose of this descriptive study was to determine the periodontal status and periodontal treatment needs (TN) of diabetes mellitus Type 2 patients attending Talaga Bodas Community Health Center.
| Materials and Methods|| |
This descriptive study adopted a cross-sectional approach. The study was conducted at Talaga Bodas Community Health Center, Bandung, from January to March 2019. Sampling was done using the purposive sampling technique. The inclusion criteria were patients who were willing to participate in the study and diagnosed with diabetes mellitus Type 2 and receiving care as part of the PROLANIS program at Talaga Bodas Community Health Center. The exclusion criterion was edentulism.
For each patient, the name, sex, address, and duration of diabetes mellitus were recorded. The research protocol was approved by the health research ethics commission of the Faculty of Medicine, Padjadjaran University (No. 52/UN6. KEP/EC/2019). Informed consent was obtained from all the participants. The periodontal tissue status and periodontal TN were determined based on the Community Periodontal Index of Treatment Needs (CPITN) index. The CPITN procedure was commenced by dividing the total number of teeth into six sextants. Each sextant consisted of teeth numbers 18–14, 13–23, 24–28, 38–34, 33–43, and 44–48. The examined teeth were teeth numbers 17, 16, 11, 26, 27, 37, 36, 31, 46, and 47. The examination was performed using a WHO probe or CPITN probe (Osung, Korea) and mouth mirror, with good lighting. The WHO probe has a working tip (ball) of 0.5 mm in diameter and markings at intervals of 3.5, 2.0, 3.0, and 3.0 mm (total: 11.5 mm) from the working tip, with black color coding between 3.5 and 5.5 mm. The ball aids the detection of calculi, rough margins of restorations, or any other irregularities on the tooth surface, and it reduces the possibility of incorrect pocket depth measurements. The WHO probe tip was inserted between the tooth surface and lateral wall of the gingival sulcus and moved around the tooth to determine the pocket depth, subgingival calculi, and bleeding response. In the examination of each tooth, the mesiolabial/buccal, midlabial/buccal, distolabial/buccal, mesiolingual/palatal, midlingual/palatal, and distolingual/palatal regions were included. Prior to the study, the operators who took the measurements were trained in the use of the CPITN index and CPITN score system.
The CPITN was used to assess the periodontal status of the patients. The scoring criteria were as follows: code 0 = healthy, code 1 = bleeding on probing, code 2 = supra- or subgingival calculus, code 3 = pockets with a depth of 4–5 mm, code 4 = pockets with a depth of more than 6 mm, and X = a sextant with <2 teeth (excluded sextant). In each sextant, the highest code value was recorded. Codes 1 and 2 were considered gingivitis, and scores 3 and 4 were considered periodontitis. Using the CPITN, the TN categories were as follows: TN 0 = no treatment (code 0), TN I = improvement in personal oral hygiene (code 1), TN II = oral hygiene + scaling (codes 2 and 3), and TN III = oral hygiene + scaling + complex treatment (code 4).,
| Results|| |
Thirty patients met the inclusion criteria of which 12 (40%) were male and 18 (60%) were female. In terms of age, 9 (30%) patients were aged 51–60 years, 13 (43.3%) patients were aged 61–70 years, and 8 (26.7%) patients were aged 70–80 years.
[Table 1] presents the results of the CPTN score; the results revealed 1 (3.3%) healthy patient, 1 (3.3%) patient with bleeding on probing, 12 (40%) patients with calculus, 9 (30%) patients with shallow pockets, and 7 (23.4%) patients with deep pockets. TN were as follows: 1 (3.3%) patient did not need treatments, 1 (3.3%) patient needed improvements in oral hygiene, 21 (70%) patients required scaling and root planing, and 7 (23, 4%) patients required complex treatment. In terms of periodontal status, 1 (3.3%) patient with diabetes mellitus had healthy periodontal tissue, 13 (43.3%) patients had gingivitis, and 16 (53.3%) patients had periodontitis.
|Table 1: Community periodontal index of treatment needs score of the subject|
Click here to view
Among the 30 patients, 123 sextants could be evaluated. Fifty-seven sextants could not be evaluated because of missing teeth. As shown in [Table 2], there were 24 (19.5%) healthy sextants, 10 (8.1%) sextants with bleeding on probing, 58 (47.2%) sextants with calculi, 23 (18.7%) sextants with shallow pockets, and 8 (6.5%) sextants with deep pockets. In terms of TN, 24 (19.5%) sextants did not require treatment, 10 (8.1%) sextants required oral hygiene, 81 (65.9%) sextants needed scaling and root planing, and 8 (6.5%) sextants required complex treatment.
|Table 2: Community periodontal index of treatment needs score based on sextants|
Click here to view
Based on the duration of diabetes and the CPITN index of patients with diabetes mellitus for 5–10 years, 5 (33.3%) patients had calculi, 6 (40.1%) patients had shallow pockets, and 2 (13.3%) patients had deep pockets. Among patients with diabetes for more than 10 years, 7 (46.7%) patients had calculus, 3 (20%) patients had shallow pockets, and 5 (33.3%) patients had deep pockets [Table 3].
|Table 3: Community periodontal index of treatment needs score based on the duration of diabetes mellitus|
Click here to view
The periodontal status and TN of the patients with diabetes for 5–10 years were as follows: 11 (6.7%) patients did not require treatment (TN 0), 1 (6.7%) patient required oral hygiene instructions (TN I), 11 (73.3%) patients required scaling and root planing treatment (TN II), and 2 (13.3%) patients required complex treatment (TN III). Among patients with diabetes for more than 10 years, 10 (66.7%) patients required scaling and root planing treatment (TN II), and 5 (33.3%) patients required complex treatment (TN III). These results showed that the duration of diabetes mellitus was correlated with the prevalence and severity of periodontal disease and the complexity of periodontal TN.
| Discussion|| |
In terms of the prevalence of the periodontal disease among patients with diabetes mellitus Type 2, periodontitis is higher than gingivitis. The TN of the diabetes mellitus Type 2 patients were mostly scaling and root planing. These results are consistent with the research of Hong et al., it has been concluded that the prevalence and risk of developing periodontal disease were higher among diabetic patients than among nondiabetic individuals. Silvestre et al. reported that as compared with nondiabetic individuals, diabetic patients had a higher gingival bleeding index and more attachment loss. Sandberg et al. showed that as compared with nondiabetes patients, periodontitis was more prevalent among diabetes patients. Diabetes patients also had more plaque and more bleeding on probing than nondiabetes patients.
Periodontal tissue destruction is commonly found in diabetes mellitus patients, with more severe and rapid development of periodontal tissue damage. A number of studies demonstrated that the risk of attachment loss and alveolar bone loss was three times higher among individuals with diabetes as compared with that among nondiabetic individuals., Diabetes mellitus was also shown to be a risk factor for periodontal disease. Diabetes-induced changes in immune cell function produce an upregulation of pro-inflammatory cytokines from monocytes/polymorphonuclear leukocytes (PMN) and downregulation of growth factors from macrophages. This predisposes to chronic inflammation, progressive tissue breakdown, and diminished tissue repair capacity. Karjalainen and Knuuttila had suggested that hyperglycemia impairs overall cell function, as insulin is required for glucose to enter cells to provide a source of energy. It also decreases PMN cell chemotaxis, phagocytosis, and intracellular killing of bacteria. The ability of glycosylated hemoglobin to carry oxygen would be impaired, thereby decreasing tissue oxygenation. Hyperglycemia induces blood flow abnormalities including increased blood viscosity, reduced erythrocyte deformability, and increased platelet aggregation, which further enhance tissue hypoxia. All these factors result in increased periodontal destruction.
The results of our study indicate a high level of periodontal TN in Type 2 diabetes mellitus patients or sextants. There were differences in TN according to the duration of diabetes mellitus, with patients with diabetes of longer duration tending to have more severe periodontal disease and greater TN than those with diabetes for a shorter duration. Longitudinal research by Taylor et al. demonstrated a correlation between the severity of periodontal disease and the duration of diabetes mellitus Type 2. In another study, the duration of diabetes was more influential in terms of the severity of periodontal disease than the age of the patients. In a study on 106 patients with diabetes mellitus Type 2, Khader et al. detected a significant association between the severity of periodontal disease and the duration of diabetes.
A study in 2017 by Denisse et al. showed that patients who had diabetes for a longer period had more severe periodontitis and a higher prevalence of periodontitis as compared with patients who had diabetes for a shorter period. In contrast, Sandberg et al. found no relationship between the duration of diabetes and periodontal status.
As shown in previous research, the duration of diabetes, combined with poor metabolic control, led to a higher prevalence of periodontal disease and increased periodontal TN. Poor oral hygiene increases the risk of periodontitis by two- to five-fold compared with good oral hygiene. Knowledge and awareness of diabetic patients regarding the impact of diabetes on periodontal disease is limited. In terms of dental and oral health care, tooth filling or tooth extraction are particularly common among diabetes patients. The lack of knowledge among diabetes patients of the importance of scaling and root planing treatments contributes to poor periodontal tissue status. Regular dental examinations can improve oral hygiene and reduce the risk of periodontitis. As reported previously, nonregular dental visits are associated with a higher prevalence of periodontitis.
Many factors contribute to the role of diabetes in the initiation and development of the periodontal disease. Poorly controlled diabetics with extensive calculus on their teeth had more periodontitis and tooth loss than well-controlled diabetics or nondiabetics. Long-duration diabetics were also at greater risk for periodontitis. Dentists can play an important role in the overall health care of diabetic patients via oral health care. Routine counseling on the importance of oral health care and periodic scaling are required to prevent severe periodontal disease in patients with diabetes mellitus.
| Conclusion|| |
The prevalence of periodontitis was higher than that of gingivitis among patients with diabetes mellitus Type 2. The TN of patients with Type 2 diabetes mellitus comprised mostly scaling and root planing. The duration of diabetes mellitus was correlated with the prevalence and severity of the periodontal disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rikawarastuti D. Diabetes melitus dan tingkat Keparahan Jaringan periodontal. J Kes Masy Nas 2015;9:277-81.
Persson GR. Diabetes and periodontal disease: An update for health care providers. Diabetes Spectr 2011;24:195-8.
Novak MJ. Classification of diseases and conditions affecting the periodontium. In: Newman MG, Takei HH, Carranza FA, editors. Clinical Periodontology. 9th
ed. Philadelphia: Saunders Publishers an Imprint of Elsevier Science; 2003. p. 64-73.
Pradeepa R, Mohan V. The changing scenario of the diabetes epidemic: Implications for India. Indian J Med Res 2002;116:121-32.
Grover HS, Luthra S. Molecular mechanisms involved in the bidirectional relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol 2013;17:292-301.
] [Full text]
American Diabetes Association. 2. Classification and diagnosis of diabetes. Diabet Care 2017;40 Suppl 1:S13-28.
Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in non-insulin-dependent diabetes mellitus. J Periodontol 1991;62:123-31.
Negrato CA, Tarzia O, Jovanovič L, Chinellato LE. Periodontal disease and diabetes mellitus. J Appl Oral Sci 2013;21:1-2.
Willkins EM. Indices and scoring methods. In: Willkins EM. Clinical Practice of the Dental Hygienist. 9th
ed. Philadelphia: Lipincott Williams and Wilkins; 2004. p. 323-45.
Bansal M, Mittal N, Singh TB. Assessment of the prevalence of periodontal diseases and treatment needs: A hospital-based study. J Indian Soc Periodontol 2015;19:211-5.
] [Full text]
Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32:281-91.1.
Singh A, Agarwal V, Tuli A, Khattak BP. Prevalence of chronic periodontitis in Meerut: A cross-sectional survey. J Indian Soc Periodontol 2012;16:529-32.
] [Full text]
Hong M, Kim HY, Seok H, Yeo CD, Kim YS, Song JY, et al
. Prevalence and risk factors of periodontitis among adults with or without diabetes mellitus. Korean J Intern Med 2016;31:910-9.
Silvestre FJ, Miralles L, Llambes F, Bautista D, Solá-Izquierdo E, Hernández-Mijares A. Type 1 diabetes mellitus and periodontal disease: Relationship to different clinical variables. Med Oral Patol Oral Cir Bucal 2009;14:E175-9.
Sandberg GE, Sundberg HE, Fjellstrom CA, Wikblad KF. Type 2 diabetes and oral health: A comparison between diabetic and non-diabetic subjects. Diabetes Res Clin Pract 2000;50:27-34.
Das M, Upadhyaya V, Ramachandra SS, Jithendra KD. Periodontal treatment needs in diabetic and non-diabetic individuals: A case-control study. Indian J Dent Res 2011;22:291-4.
] [Full text]
Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000 2007;44:127-53.
Linares-Vieyra C, González-Guevara MB, Rodríguez-de Mendoza LE. [Periodontal diseases and treatment needs in diabetes type 2]. Rev Med Inst Mex Seguro Soc 2009;47:129-34.
Karjalainen KM, Knuuttila ML. The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin dependent diabetes mellitus. J Clin Periodontal 1996;23:1060-7.
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M, Knowler WC, et al
. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. J Periodontol 1996;67:1085-93.
Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population. Community Dent Oral Epidemiol 2002;30:182-92.
Khader YS, Albashaireh ZS, Hammad MM. Periodontal status of type 2 diabetics compared with nondiabetics in north Jordan. East Mediterr Health J 2008;14:654-61.
Denisse DM, Nelly MF, Enrique CC, Enrique G, ERR R, Omar TM, et al
. Relationship between periodontal disease and type 1 diabetes in adolescents. Ann Med Health Sci Res 2017;7:350-4.
Rajhans NS, Kohad RM, Chaudhari VG, Mhaske NH. A clinical study of the relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol 2011;15:388-92.
] [Full text]
Lertpimonchai A, Rattanasiri S, Arj-Ong Vallibhakara S, Attia J, Thakkinstian A. The association between oral hygiene and periodontitis: A systematic review and meta-analysis. Int Dent J 2017;67:332-43.
[Table 1], [Table 2], [Table 3]