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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