Periodontal Disease Among Diabetics in Iraq

Abstract and Introduction

Abstract

Background

It is generally accepted that diabetes increases the prevalence and severity of periodontitis, and is now considered the sixth “-opathy” of diabetes. The aim of this study was to determine the prevalence of periodontal disease in patients with type 2 diabetes mellitus and assess their severity in a single center in Basrah, Iraq.

Methods

This was a cross-sectional, case-control study. A total of 1593 patients were included (633 diabetic patients and 960 nondiabetics as controls). Patients with type 2 diabetes mellitus who were dentate persons aged 40 years and older and with ≥ 6 remaining teeth were studied.

Results

Periodontal disease was seen in 95.9% of both diabetics and controls. Concerning mild and advanced disease, there was no difference between diabetics and controls, whereas moderate disease was more prevalent in those with diabetes.

Conclusion

Of both the diabetics and controls, periodontal disease was seen in 95.9%. Moderate disease was significantly more common among diabetics. Larger studies, with pocket depth – attachment loss with radiologic evaluation for bone loss – are needed to assess the prevalence of periodontal disease among diabetics, other systemic disease, and the general population.

Introduction

Periodontitis (periodontal disease) is a persistent bacterial infection causing chronic inflammation in periodontal tissues. It is characterized by the formation of pathologic periodontal pockets concomitantly with destruction of the periodontal ligament fibers attaching teeth to the alveolar bone and alveolar bone itself.[1]

It is generally accepted that diabetes increases the prevalence and severity of periodontitis, and is now considered the sixth “-opathy” of diabetes.[2–4] Elevated glucose levels and the accumulation of advanced glycation end products (AGEs) in the gingival tissue of individuals with diabetes are thought to be primarily responsible for oral and other complications of diabetes.[5,6] Other pathophysiologic changes in diabetics that may predispose to periodontal disease include reductions in leukocyte chemotaxis, phagocytosis, and bactericidal activity as well as reduced cellular immunity.[7] Greater vascular permeability in AGE-enriched gingival tissue will lead to greater breakdown of collagen fibers and accelerated destruction of both connective tissue and bone, which is the hallmark of periodontal disease.[8]

People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those who are older, those with diabetes of long duration, or those with other complications of diabetes.[9] Those with poor control had more attachment loss and were more likely to exhibit recurrent disease.[10]

Periodontitis is seen in both type 1 and type 2 diabetics.[8] It will worsen the control of diabetes mellitus (DM),[11] and control of periodontal disease will improve the DM.[12] Chronic gram-negative bacterial infections of periodontal tissues may reduce insulin-mediated glucose uptake by skeletal muscle and may produce whole-body insulin resistance. Effective treatment of periodontal disease was associated with a reduction in the level of glycated hemoglobin and a reduction in the level of AGEs in the serum, and control of periodontal infections may be an important part of the overall management of diabetic patients.[13,14]

Patients with well-controlled diabetes who have good oral hygiene and who are on a regular periodontal maintenance schedule have the same risk of severe periodontitis as nondiabetic subjects.[15]

Periodontal disease was discovered as a strong predictor of mortality from ischemic heart disease and diabetic nephropathy in patients with type 2 diabetes.[16]

The aim of this study was to determine the prevalence of periodontal disease in patients with type 2 DM and assess their severity in a single center in Basrah, Iraq.

Methods

This was a cross-sectional, case-control study. In the period from November 2003 to March 2005, a total of 1593 patients were included (633 diabetic patients and 960 nondiabetics as controls). The patients were attending the outpatient diabetic clinic in Al-Faiha Hospital in Basrah. Included patients were type 2 DM patients who were dentate persons aged 40 years and older with ≥ 6 remaining teeth. Patients who were edentulous were excluded. The controls were nondiabetic patients who were visiting the outpatient clinic for other reasons. All patients gave an informed consent, and the study was approved by the ethical committee of the College of Medicine in Basrah.

DM was diagnosed according to the American Diabetes Association recommendations in 2002.[17] Patients who were on drug treatment for diabetes were considered diabetic. Education level was calculated according to the number of years of school achievement. Patients who were cigarette smokers were considered smokers, whereas those who had already quit smoking for at least for 1 year were considered nonsmokers. Dentists performed the dental examinations. The oral health examination included an examination of the oral cavity to assess tooth count and location. Flossing and brushing were reported. Brushing 2 times per day with or without flossing was considered proper dental care and considered doing brushing. None of our patients practiced cleaning interdental spaces daily.

We used the same principles of the of Third National Health and Nutrition Examination Survey (NHANES III) (1988–1994).[18] The periodontal probe PCP 11 (Hu-Friedy, Chicago, Illinois) was used to assess probing depth. The data were collected when slight resistance to probe penetration was felt. The periodontal examination was carried out in 2 randomly selected quadrants, one maxillary and one mandibular. All fully erupted teeth in these 2 quadrants were assessed, excluding the third molars. A maximum of 14 teeth per individual were examined for periodontal parameters. Advanced periodontitis included persons who have 2 or more teeth (or ≥ 30% of the examined teeth) with ≥ 5 mm probing depth, or 4 or more teeth (or ≥ 60% of the teeth) with ≥ 4 mm probing depth. Moderate periodontitis included persons without advanced periodontitis who have 1 or more teeth with ≥ 5 mm probing depth, or 2 or more teeth (or ≥ 30% of the teeth) with ≥ 4 mm probing depth. Mild periodontitis included persons without moderate or advanced periodontitis who have 1 or more teeth with ≥ 3 mm probing depth. Persons who had 6 or more teeth present and who were without the aforementioned criteria of periodontitis were classified with no periodontitis.[18]

The total number of patients was 1593; of them, 633 were diabetic patients and 960 were controls.

Statistical Analysis

Continuous variables were summarized as the mean ± SD. Categoric variables were summarized as percentages. For statistical analysis a chi-square test was used. A comparison of 2 means was carried out with an unpaired Student t test. The level of significance was set to be < .05 throughout the analysis.

Results

The demographic characteristics of 1593 patients are listed in Table 1. The mean age of diabetics was 56.7 ± 9.6 vs 56.9 ± 11.3 years in the control group. The predominant sex in this study included women (53.3% of diabetics and 56.1% of the controls). Brushing at least 2 times a day was seen only in 3.7% and 1.6% of the diabetics and controls, respectively. Of diabetics, 78.6% were smokers vs 76.5% of the controls. There was no difference between the diabetics and controls in mean age, sex, educational level, tooth care (a least 2 times a day brushing), and smoking.

Table 1.

Characteristics of Patients and Control

Characteristic	Diabetes Mellitus n* (%)	Control n (%)	P Value	Total n(%)
Age years (mean ± SD)	56.7 ± 9.6	56.9 ± 11.3	.9	56.9 ± 10.7
Sex: men n (%)	295 (46.6)	421 (43.8)	.3	716 (44.9)
women n (%)	338 (53.3)	539 (56.1)	.3	877 (55)
Education level (mean ±SD)	4.3 ± 5.6	3.8 ± 5.5	.9	4 ± 5.5
Brushing n (%)	24 (3.7)	16 (1.6)	.2	40 (2.5)
Smoking n (%)	498 (78.6)	735 (76.5)	.3	1233 (77.4)
Total n (%)	633 (100)	960 (100)		1593 (100)

^*n denotes number

Classification of periodontal disease according to severity is represented in Table 2. Of both the diabetics and the controls, periodontal disease was seen in 95.9%. For mild and advanced disease, there were no differences between the diabetics and controls, whereas moderate disease was more common in those with diabetes. Advanced disease was reported in 60.1% of the diabetics and 61.8% of the controls.

Table 2.

Periodontal Disease According to Severity

Periodontal Disease	Diabetics n (%)	Control n (%)	P Value	Total
Normal	22 (3.4)	44 (4.5)	.3	66 (4.1)
Mild	80 (12.6)	146 (15.2)	.1	226 (14.1)
Moderate	150 (23.6)	176 (18.3)	.01	326 (20.4)
Advanced	381 (60.1)	594 (61.8)	.9	975 (61.2)
Total	633 (100)	960 (100)	–	1593 (100)

Discussion

The education level of our patients and controls was low. The oral hygiene was very poor; only 2.5% of the included patients were brushing at least 2 times a day. Spangler and Konen[19] studied oral health behaviors among patients with type 1 and 2 DM. The percentage of diabetic patients who were brushing daily was 74% (both diabetes type 1 and 2); 34% and 30%, respectively, flossed on a daily basis; and 23% and 40%, respectively, made dental visits at least annually. Syrj and colleagues[20] reported a 50% rate for brushing twice daily, daily interdental cleaning in 15%, and dental attendance at least annually in 54%. Despite that, Bartold and colleagues[21] concluded that improved oral hygiene has little effect on the incidence of severe periodontal disease, and successful management of the disease relies on the continuous assessment of at-risk patients and regular, thorough subgingival debridement.

The majority of our patients were smokers (77.4%). Smoking increases the risk of periodontal disease by nearly 10 times in diabetic patients.[22] Smoking may not only be associated with the development of periodontal diseases, but it may affect the successful outcome of periodontal treatment, and the management of diabetic patients should include strong recommendations to quit smoking.[23]

With pocket depth as a marker of severity of periodontal disease in this study, only moderate disease was more common among the diabetics than the controls. This has been reported. No significant associations between DM and periodontal disease severity were found if the relative frequency of deep periodontal pockets was used as the clinical parameter for periodontal disease severity.[24] However, diabetes has been found to be significantly correlated with the number of lost teeth, which is again one marker of disease.

In Brazil, comparing the diabetic and the control groups as a whole, there was no statistically significant difference in probing pocket depth, but significance was observed for attachment loss.[25] In a large cross-sectional study, Grossi and colleagues[26] showed that diabetic patients were twice as likely as nondiabetic subjects to have attachment loss.

Of our patients, 95.9% had some periodontal disease. In a nationwide study among Finnish adults 30 years and older, 77% had pathologic pockets.[27] In the NHANES III (1988–1994) on the dental health of Americans aged 35–44 years, 12.3% of examined persons had at least 1 tooth with an attachment loss > 5 mm, and 3.8% had at least 1 tooth with a periodontal pocket > 6 mm.[28] The differences may be due to younger age of the Americans because the prevalence of periodontal disease increases with age.[29] However, it may indicate more severe disease among our population as a whole. In Quebec, Ontario, Canada, adults aged 35–44 years who are not completely edentulous have at least 1 tooth with a periodontal pocket of 4–5 mm, and 1 person out of 5 has a periodontal pocket of > 6 mm.[30]Our study had its limitations. We used only pocket depth as a marker of disease, but attachment loss and number of missed teeth may correlate more with periodontal disease. Furthermore, it was a single-center experience and could not represent the whole population in Basrah. Nevertheless, one study from Ninevah, Northern Iraq, showed that periodontal disease was seen in 87.5% of persons.[31] And in the Eastern Mediterranean Region, in Lebanon, the prevalence of periodontal disease reaches as much as 94.5%.[32]

Conclusion

Of both the diabetics and the controls, periodontal disease was seen in 95.9%. Moderate disease was significantly more among diabetics. Larger studies with pocket depth, attachment loss with radiologic evaluation for bone loss, are needed to assess the periodontal disease among diabetics, other systemic disease, and the general population.