Sana F.doc J Bagh College Dentistry Vol. 25(Special Issue 1), June 2013 Regulation of Oral and Maxillofacial Surgery and Periodontics 102 Regulation of HbA1c of uncontrolled diabetic type II obese and normal weight patients by oral hygiene performance (Comparative study) Sana F. Hadratie, B.D.S. (1) Abdullatif A.H. Al-Juboury, B.D.S., Ph.D. (2) ABSTRACT Background: The association between periodontal diseases incidence and development and the metabolic diseases as Diabetes Mellitus and Obesity are recently have attract great deal of researchers attention and investigation. The periodontal health proved to reduce the systemic inflammatory reactions and positively improve the glycemic control of diabetes Type2 patients. The aim of the study was to investigate the influence of oral hygiene control on the glycemic control of obese and normal weight moderately controlled Diabetic Type 2 patients, in addition to study the association of obesity with the gingival inflammation. Materials and Methods: Cross sectional study of three months duration. Included 30 moderately controlled diabetic type2 patients who attend the Specialist Center for Endocrine and Diabetes diseases Baghdad Al-Russafa administration / Iraqi Ministry of Health, were grouped into two groups, G1 of normal weight diabetics, and G2 obese diabetics according to their BMI level, the oral hygiene status measured by their PLI,GI,BBOP,PDI,CAL was conducted at each of the five visits of three weeks interval between each till the end of three months duration of the study and the level of their glycemic control measured by HbA1c level was conducted at the first and the fifth visit of the research duration , BMI was measured at the first and the fifth visit also. Paired t-test, ANOVA, Qui-square and Pearson correlation statistical analysis was used to investigate the significance of the improved glycemic control after oral hygiene control (OHC) of both G1 and G2. Results: periodontal parameters of both G1 and G2 were significantly improved after OHC with a significant reduction in HbA1c level of both normal weight and obese patients. Conclusion: The Oral Hygiene Control (OHC) is sufficient to improve reduction in Diabetes control level with or without overweight.OHC home care and professional measures could improve the gain in periodontal health in normal weight diabetics and overweight diabetics Obesity has an association with the presence of bleeding on probing as an indicator of the gingival inflammation in diabetic Type2 patients. Key words: Periodontitis, diabetes Type II, oral hygiene. (J Bagh Coll Dentistry 2013; 25(Special Issue 1):102-107). INTRODUCTION Diabetes Mellitus, the clinical syndrome characterized by hyperglycemia caused by absolute or relative deficiency of insulin (1).The prevalence of diabetes for all age-groups world- wide was 2.8% in 2000 and estimated to be 4.4% in 2030. The prevalence was higher in men than in women (2). About 85%-90% of diabetic cases are type 2 DM, while type 1 constitutes 5%-10% of the cases (3).Obesity is a global rising problem all over the world; can be defined as an excess amount of body fat in proportion to the lean body mass (4) to the extent that health is impaired (5). The world health organization WHO defines obesity as a BMI > 30 (5) which in turn reflected by increased waist circumference (6),Certain ethnic groups seem to be more sensitive than the other to develop its adverse metabolic effects than the others that high levels of diabetes and related diseases are found in south Asia and Arab populations (6). The Adipose tissue (Body fat) is no longer considered as a storage of Triglycerides, but a complex and metabolically active endocrine (1) Master student. Department of Periodontics. College of Dentistry. University of Baghdad. (2) Professor. Department of Periodontics. College of Dentistry. University of Baghdad. organ that secretes numerous immunomodulatory factors collectively called adipokines, where some of them act locally and the others released into the systemic circulation to act as signaling molecules to the liver , muscles , and endothelium (7).Through these immune factors obesity emerged one of the risk factors of developing periodontal diseases, Systemic health problems such as diabetes type 2 and cardiovascular diseases (8).Through these immune factors obesity emerged one of the risk factors of developing periodontal diseases. The effect of DM on the periodontal diseases development: Although periodontitis is a recognized complication of diabetes, people with well-controlled diabetes who have good oral hygiene are not at increased risk of developing periodontitis. However, their susceptibility to periodontitis is significantly increased when their diabetes is poorly controlled, particularly if they are smokers (9). In addition they are at high risk of disease progression (10). Type of microbial oral flora in diabetic was studied by many researchers, Campus et al showed a higher prevalence of P.gingivalis was demonstrated in type 2 diabetics compared to non-diabetic control subjects using polymerase chain reaction (PCR) On using checker board DNA-DNA hybridization , J Bagh College Dentistry Vol. 25(Special Issue 1), June 2013 Regulation of Oral and Maxillofacial Surgery and Periodontics 103 Treponema denticola , streptococcus sanguinis ,prevotella, nigrescens , staphylococcus intermedius and streptococcus oralis levels were elevated in supra-gingival plaque of diabetic compared to non-diabetics, although, no significant differences were found in the sub- gingival plaque samples(11).The periodontal tissues with large amounts of AGEs content are characterized by higher shared susceptibility between these two common diseases can be summarized as (12): • Role of biochemical changes including hyperglycemia and AGEs formation. • Role of immunological activity such as cytokines and adipokines (in obese diabetic patients) such as IL-6 and TNF-α. Role of Advanced Glycation End-products (AGEs): AGEs are the result of non-enzymatic glycation and glycoxidation processes and are formed on proteins ,lipids and nucleic acids in a pro-oxidant environment , their formation is enhanced with concomitant hyperglycemia and delayed macromolecular turnover(13) AGEs may be deposited on mononuclear polymorphonuclear cells, inhibiting their chemotactic and phagocytic capacities and permitting the advance of gram- negative anaerobic bacteria, which explain the high prevalence and severity of periodontal diseases in diabetic patients(14) . Diabetics have defective neutrophil apoptosis which may result in increased retention of PMNL within the periodontal tissues and contribute to tissue destruction by non-specific release of Matrix Metalo-Proteinase MMPs and reactive oxygen species (ROS),providing a further mechanism for increased susceptibility to periodontal diseases In addition , AGE-stimulated macrophages and PMNL cells releasing a larger amount of cytokines and soluble mediators and producing a greater destruction of C.T in these patients as a hyper-response to. The progression of bacterial biofilm 15, 16) Role of Immunological activity (cytokines and adipokines): Type2 diabetes is proposed to cause substantial changes in immunologically active molecules and perturb the finally ,balanced cytokine networks within the periodontium, which in turn affect the localized immune responses and altered the susceptibility to periodontal diseases.(17) The inflammation associated with the periodontal diseases , characterized by elevated pro- inflammatory cytokines ,innate immune receptor expression (TLR-4) and cellular infiltrate is exacerbated in with type 2 diabetes, with a feed forward loop regulated by poor glycemic control was associated with a loss of mucosal barrier integrity and accumulation of innate immune receptor ligands resulting in an exacerbation of an ongoing inflammation(18) Effect of periodontitis on diabetes mellitus: Periodontal diseases are prevalent in most populations and may have wide-range of systemic effects in susceptible individuals and may act as a potential independent risk factor for diabetic complication and exacerbating the existing disorder of the patient.(19)Evidence suggests that periodontitis –induced bacteremia cause an elevation in serum pro-inflammatory cytokines (IL-1β and TNF-α) which have been demonstrated to produce alterations in lipid metabolism leading to hyperlipidemia and alternately causing an insulin resistance syndrome and contributing to destruction of pancreatic B- cells leading to the development of diabetes(20) Persistent elevation of IL-1β,IL-6 ,TNF-α in the diabetic state have an effect on the liver ,stimulate the release of acute-phase proteins CRP ,produce the characteristic dysregulation of lipid metabolism associated with type2 diabetes and have an effect on pancreatic B-cells as well.(21) Obesity and periodontitis: Obesity has both local and systemic inflammatory networks by which obesity exert its effects on the body systems, these networks governed by the secretion of adipokines, pro-inflammatory cytokines and reactive oxidative species. The first reported observation on the relationship between obesity and the periodontal diseases was made by Perlsteinet al.in 1977; they observed histopathological changes in the periodontium in hereditary obese Zucker rats. On using ligature- induced periodontitis, they found alveolar bone resorption to be greater in obese animals compared with non-obese rats that the obese- hypertensive rats showed the most severe periodontal response to local irritation (22). Based on reviewing the NHANES III, obesity could be a potential risk factor for periodontal diseases especially among younger individuals andthat promotion of healthy nutrition and adequate physical activity may be additional factors to prevent the rate of progression of periodontal diseases. (23) As obesity is generally the first step toward type2 DM, it is possible to find exacerbated periodontal diseases in obese patients (24). Obese subjects with a high serum triglyceride level and/or a low HDL-cholesterol level could be at higher risk of periodontal infection. And that the association between body weight and periodontal infection was mainly mediated through a mechanism other than serum lipids (25). The relationship between obesity and periodontal diseases is Dose-dependent relation that, overweight individuals had double the J Bagh College Dentistry Vol. 25(Special Issue 1), June 2013 Regulation of Oral and Maxillofacial Surgery and Periodontics 104 incidence ,while obese had triple the incidence ,severity and extent of periodontal diseases.(26) Obesity showed correlation with greater attachment loss in obese than in non-obese(27) Effect of periodontal diseases on obesity: Some studies suggest that periodontal pathogens can contribute to obesity development. Goodson’s et al, suggest three mechanisms by which oral bacteria may contribute to the development of obesity, the first hypotheses suggests that oral bacteria may contribute to increased metabolic efficiency .the second suggest that oral bacteria could increase weight gain by increasing appetite, and the third one suggests that oral bacteria redirect energy metabolism by facilitating insulin resistance through increasing levels of TNF-α or reducing levels of adiponectin. By any of these three mechanisms, even a small calorie consumption with no change in diet or exercise could result in an unacceptable weight gain (28) The effect of oral bacteria on obesity development is further confirmed through the effect of periodontal treatment aimed at elimination of the periodontal -pathogens on the improvement in the lipid profile of treated patients, as was observed by Tandon et al (29) Effect of periodontal treatment on glycemic control of diabetics: The anti-inflammatory periodontal treatment (scaling and root planning ) can be hypothesized to improve insulin sensitivity by reducing the peripheral TNF-α concentration and by which exert a beneficial effect on the metabolic control of Type2 diabetic patients.(30) A meta-analysis of ten intervention studies to estimate the effect of periodontal treatment on HbA1c found a weighted mean reduction of 0.66% in type 2 DM patients ,however, this did notachieve a statistical significance.(31) The prevention of periodontal disease is an important diabetic task , that an aggressive management of oral health and regular check-up in diabetic patients may diminish the inflammatory effects on diabetes control.(32)Reduction of periodontal inflammation either with root planning and systemic antibiotics or with plaque control and sub-gingival scaling significantly reduces CRP levels (33), significant decrease in total and LDL cholesterol levels (34), and decrease in the level of some circulating pro-inflammatory cytokines and may be associated with a decrease in insulin resistance in the obese patients (35). MATERIALS AND METHODS After gaining the college ethical committee’s approval on the study protocol and the Iraqi Ministry of Health approval on the use of human subjects in this study ,the sample recruited for the study were patients attending the specialized center for Endocrinology and Diabetes ,and Al- Kindy teaching hospital -Baghdad /Al-Russafa administration.30 of moderately controlled diabetic type 2 patients were participated and divided into two groups according to their BMI level into G1 of normal weight (BMI>=22) and G2 obese patients (BMI>=30)both having moderate chronic periodontitis of pocket depths>=4mm and clinical attachment loss >=6.00 mm. both groups participants are uncoholic ,non-smokers ,with no previous periodontal treatment or systemic medication Other than their hypoglycemic drugs for about two months before or during the study. An adequate elimination of the sub-gingival plaque, in addition to the use of Chlorehexidine mouth wash twice a day for the week after scaling). RESULTS Both groups were at the same level of the metabolic control at the beginning of the study (day zero) {table 1}. The Oral Hygiene Control (OHC) measures included the daily home care (teeth brushing, flossing and interdental brushing) enforced by the professional scaling at the first visits. PLI,GI,BOP,PDI,and CAL were recorded at day zero and reevaluated for the next four visits (with three weeks interval between each), BMI, and HbA1c levels were measured at day zero and after three months to adjust the effect of the oral hygiene control measures on the glycemic control of each group.After three months of OHC, the HbA1c level showed a highly statistical reduction in both groups(G1 and G2) with no significant reduction in BMI level forboth groups.{table2,3},Oral Hygiene status measured by PLI,GI, and BOP showed Highly significant reduction for both groups {tables 4,5}, The pocket depth index show a highly significant reduction in G1 accompanied by highly significant reduction in CAL {table 4}while, in G2 the highly significant reduction in PDI was accompanied by not significant reduction in CAL {table 5}.The intergroup comparison of the pocket depth reduction showed significant difference after OHC, while attachment gain , PLI ,GI ,and BOP show no significant difference {table 6}. Chi- square analysis of the effect of obesity on the health status of the periodontium of both normal weight and obese diabetic patients calculated by BOP index before and after OHC revealed that Obesity do have an association with the severity of bleeding on propping in both groups {table 7}. J Bagh College Dentistry Vol. 25(Special Issue 1), June 2013 Regulation of Oral and Maxillofacial Surgery and Periodontics 105 Table1: the intergroup comparison of the metabolic control of both groups At Day zero Sig. P-value 3 months after treatment Sig. P-value mean±SD mean±SD HbA1c 0.593±1.255 0.857 NS 0.357±1.327 0.315 NS Table2: Analysis of the metabolic parameters of G1 (normal weight) before and after OHC: Metabolic parameter Time of reading mean ±SD t-test P- value HbA1c day zero 3 mon. later 8.457±0.897 7.519±0.977 3.283 0.005 HS BMI day zero 3 mon. later 24.128±0.997 23.866±1.435 1.69 0.112 NS Table 3: Analysis of the metabolic parameters of G2 (Obese) before and after OHC. Metabolic parameter Time of reading Mean ±SD t-test P-value HbA1c day zero 3mon. later 8.397±0.70 7.233±0.72 7.41 0.001 HS BMI day zero 3mon.later 32.246±2.17 32.264±2.2 0.213 0.834 NS Table 4: Analysis of the periodontal parameters of G1 (Normal weight) before and after OHC. Table 5: Analysis of the periodontal parameters of G2 (Obese) before and after OHC. Time of reading Mean ±SD t-test df P-value PLI day zero 3mon. later 1.082±0.37 0.054±0.07 10.823 14 0.001 HS GI day zero 3mon. later 1.453±0.40 0.467±0.38 8.787 14 0.001 HS BOP day zero 3mon.later 0.54±0.36 0.007±0.02 5.730 14 0.001 HS PDI day zero 3mon. later 4.649±0.77 2.293±1.01 10.28 14 0.001 HS CAL day zero 3mon. later 5.788±1.44 4.842±1.30 2.123 14 0.049 NS Time of reading Mean ±SD t-test df P value PLI At day zero 3 mon. later 1.031±0.47 0.096±0.06 7.843 14 0.001 HS GI At day zero 3 mon. later 1.451±0.58 0.065±0.48 6.206 14 0.001 HS BOP At day zero 3 mon. later 0.68±0.36 0.09±0.18 6.286 14 0.001 HS PDI At day zero 3 mon. later 5.024±1.25 3.257±1.18 12.9 14 0.001 HS CAL At day zero 3 mon. later 6.684±1.30 5.788±1.44 5.214 14 0.001 HS J Bagh College Dentistry Vol. 25(Special Issue 1), June 2013 Regulation of Oral and Maxillofacial Surgery and Periodontics 106 Table 6: Intergroup comparison between the periodontal parameters before and after OHC. Periodontal parameter At Day Zero Sig. (p-value) 3 months later Sig. (p-value) Mean difference ± SD Mean difference ± SD PLI -0.506±0.726 0.791 NS 0.416±0.105 0.149 NS GI -0.020±0.695 0.991 NS 0.191±0.405 0.89 NS BOP 0.144±0.56 0.337 NS 0.085±0.16 0.062 NS PDI 0.374±1.468 0.34 NS 0.964±1.453 0.022 S CAL 0.896±1.684 0.058 NS 0.946±1.952 0.082 NS Table 7: Chi-square analysis of association of BOP and Obesity before and after OHC. BMI BOP scores Before OHC Chi-square df P-value at 0.05 Sig. 0 1 No. % No. % Normal weight 412 33.22 828 66.77 33.88 1 3.84 S obese 630 49.14 652 50.85 0.059 NS DISCUSSION As periodontal infections contributed to elevated serum inflammatory mediators such as TNF-α, IL-6 and PGE2, as an innate inflammatory hyper responsiveness to the bacterial challenge, TNF- α and IL-6 proved to induce Insulin Resistance and worsen the hyperglycemic state of the diabetics. Obese diabetic patients have high levels of serum TNF- α and other inflammatory mediators that affect the diabetic control and the periodontal health as well.In our study, 30 patients of moderately controlled type 2 diabetes were participated ,divided into two groups according to their BMI level, as G1 , consist of 15 normal weight diabetics and G2 consist of 15 obese diabetics. Both of G1 and G2 were instructed to the proper daily oral hygiene performance, reinforced at different intervals through the visits of the study according to the patients need and scaling to eliminate the bacterial plaque and calculus as a professional partof OH performance. The effect of OH performance and control on the glycemic control of diabetics is measured by HbA1c test before and after three months of scaling and OH performance. Both groups were at the same OH status before treatment, After three months of OHC measures, PLI, GI and BOP showed insignificant difference in intergroup analysis indicating an equal OH status and patients’ compliances to the OH instructions , that both G1 andG2 showed a highly significant reduction in PLI , GI and BOP as described in {tables 4,5} . PDI showed significant difference in the intergroup analysis {table 6} with no significant difference in CAL between the two groups after three months of OHC, Which could indicate a slight difference in the inflammatory response between the groups, That the insignificant difference in intergroup analysis of the CAL with difference in the PDI means that the pocket formed due to enlarged inflamed gingival tissues despite the loss of attachment present as a destructive periodontal disease progression in both groups. The insignificant difference in CAL between the groups {table 6} indicates that obesity showed insignificant effect on the outcome of the periodontal treatment of diabetic patients. The improvement in the oral hygiene status was accompanied by a significant reduction in HbA1c in both groups. BMI level of G1 showed slight but not significant reduction after three months of treatment {table 2}, that indicates the presence of weight-loss due to the lipolysis that resulted from uncontrolled hyperglycemia of the diabetic and insulin resistance state. While G2 showed slight but not significant elevation of BMI after three months of the study, which could be resulted from the improved periodontal inflammation that enabled the patients to eat better than before {table 3}. Chi-square test {table7} of BOP of both groups before and after the OHC showed that obesity could have an association with the gingival inflammation measured by the presence of the bleeding sites of both groups. 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