The glycosylated hemoglobin assay for diabetes: its value to the periodontist. Two case reports

Effect of Scaling and Root Planing in Conjunction with Antimicrobial Therapy on Glycated Hemoglobin Levels in Type 2 Diabetes Mellitus Patients

Background

Scaling and root planing with systemic doxycycline had an effect on blood glucose levels in type 2 diabetes patients, according to the results of a glycosylated hemoglobin assay. The trial was conducted to determine whether periodontal therapy affected blood sugar regulation as a result of this finding.

Methods

A total of 60 people with type 2 diabetes (diabetes mellitus not caused by insulin deficiency) were split into three groups. Group I (control group) consists of patients who are only taking an oral anti-diabetic medication. Patients on an oral anti-diabetic drug plus scaling and root planing make up group II. Patients on an oral anti-diabetic drug, scaling, root planing, and doxycycline constitute Group III. The patients were re-evaluated for glycated hemoglobin levels and periodontal status using the clinical parameters of gingival index by Loe and Silness and clinical attachment level at baseline, 30th, 60th, and 90th day.

Results

Compared with group II, the findings showed a statistically significant decrease in glycated hemoglobin values (p =0.001) and improvements in clinical attachment level (p =0.022, 0.05) and gingival index (p = 0.009.,01) in group III. In the control group (group I), no such finding was made. The average gingival index, however, increased statistically significantly (p = 0.032, 0.05).

Conclusion

Various studies have been showing the benefits of non-surgical periodontal therapy as a benefit for improving the overall glycemic status of the patient. Non-surgical mechanical periodontal therapy combined with systemic administration of antimicrobials such as doxycycline enhances the metabolic status of type 2 diabetes mellitus patients better than non-surgical mechanical periodontal therapy alone.

Effect of Conventional Periodontal Treatment (Scaling and Root Planing) on Type-2 Diabetic Patient with Moderate Generalized Chronic Periodontitis: A Clinical Study

Background:

The aim is to assess the effect of periodontal therapy and scaling and root planing (SRP) on the metabolic control in Type 2 diabetes mellitus (DM) patients with chronic periodontitis based on the estimation of glycated hemoglobin (HbA1c).

Materials and Methods:

A prospective, comparative, clinical study was performed on 50 patients suffering from Type 2 DM with moderate, generalized chronic periodontitis. Type 2 moderately controlled diabetic patients with HbA1c values within the range of 6%–8% were selected. The parameters recorded were gingival index, plaque index, sulcus bleeding index, probing pocket depth, clinical attachment level, and HbA1c. The recordings were done at baseline and 6 months after SRP procedures.

Results:

Reductions in all the clinical parameters were observed and were found to be statistically significant (P < 0.05).

Conclusion:

SRP resulted in a statistically significant reduction in the clinical parameters and HbA1c. Hence, periodontal treatment should be included in the management of diabetic patients.

Effect of Non-Surgical Periodontal Therapy on the Serum Sialic Acid Levels in Diabetic Patients with Periodontitis

Sialic acid (SA), a family of acetylated derivatives of neuraminic acid, an acute phase reactant by itself. It usually occurs as a terminal component at the non-reducing end of carbohydrate chains of glycoproteins and glycolipids. SA participates in multiple physiological functions, such as cell-to-cell interactions, cell migration and proliferation. Diabetes mellitus (DM) is a chronic metabolic disorder characterized by rise in blood glucose level. Periodontitis is a chronic inflammatory disease of the periodontal tissue, leading to destruction of bone surrounding the tooth and ultimately tooth loss. There is a two way relationship between diabetes mellitus and periodontitis. Periodontitis is the sixth complication of diabetes along with retinopathy, nephropathy, neuropathy, macrovascular disease, and altered wound healing. Inflammatory mediators like interleukin-6 and tumor necrosis factor-alpha produced during periodontal inflammation can interfere with the actions of insulin receptors and worsen the glycemic control of diabetic patients. Periodontitis is a major cause of tooth loss, affecting over 300 million people and bacteria associated with periodontitis are also linked with systemic problems like endocarditis, atherosclerosis. Recent work has highlighted a major role for the host sugar sialic acid in the biofilm physiology and host-pathogen interactions of T. forsithya, a key periodontal pathogen. There exists a need for a biomarker, for early detection of disease evolution and more robust therapy efficacy measurements. Serum sialic acids were estimated in Indian population by diphenylamine method and Thiobarbituric acid method. The average values were 68 ± 2.6 mg percent by DPA method and 56 ± 5 mg percent by TBA (thiobarbituric acid assay) method. Age and sex showed no influence on serum sialic acid level. Objectives of the present study was to compare (TSSA) level in healthy subjects, subjects with (CMP) with and without (NIDDM) and its effect on non-surgical periodontal therapy. In the present study, the participants were divided into three groups: Group A, B and C. Group A consists of systemically healthy subjects, Group B consists of subjects with (CMP) while Group C consists of subjects with (CMP) with (NIDDM) and results of this study indicated that, at baseline, there were significant differences between Group A, B and Group C with respect to all the clinical parameters, including (GI), (OHI-S), (PPD), (CAL), (TSSA) and (HbA1c) levels. Thus (TSSA) level could be considered as novel biomarker in the progression of periodontal disease and diabetic status. Periodontitis could be considered as a potential, modifiable, and independent risk factor for the development of diabetes. Early detection of elevated (TSSA) level may help in interpreting the progression of periodontitis, risk of development of diabetes mellitus in future and also to prevent complications.

Comparison of glycated hemoglobin levels in individuals without diabetes and with and without periodontitis before and after non-surgical periodontal therapy

BACKGROUND

Only a few studies have examined the association between periodontitis and glycated hemoglobin (HbA1c) levels in individuals without diabetes. The aim of this study is to compare HbA1c levels in individuals without diabetes and with and without periodontitis before and after non-surgical periodontal therapy.

METHODS

This comparative study was done on individuals without diabetes who were 35 to 65 years old. Group A consisted of 30 individuals without periodontitis, and group B consisted of 30 individuals with periodontitis. Body mass indices and clinical parameters, including oral hygiene index-simplified (OHI-S) score, gingival index (GI), probing depth (PD), clinical attachment level (CAL), and HbA1c level, of all participants were recorded. All participants received non-surgical periodontal therapy (scaling and root planing). After 3 months, all participants were reexamined, and clinical parameters and HbA1c levels were evaluated and compared to baseline values.

RESULTS

There were significant differences between group A and group B in regard to baseline OHI-S, GI, PD, and HbA1c (P <0.05). There was no clinical attachment loss in group A, either at baseline or after 3 months. At the end of 3 months, group B showed improvement in all clinical parameters (P <0.05) and their HbA1c levels also significantly decreased (P <0.05), although the values never reached those of group A.

CONCLUSION

The HbA1c levels of individuals without diabetes and with periodontitis (group B) were significantly reduced 3 months after non-surgical periodontal therapy, although they never reached the same levels as those of the individuals without diabetes or periodontitis (group A).

The effect of full-mouth tooth extraction on glycemic control among patients with type 2 diabetes requiring extraction of all remaining teeth: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Several studies have shown that periodontitis can complicate the severity of diabetes by worsening the degree of glycemic control. The purpose of this study was to determine the effect of full-mouth tooth extraction on glycemic control among type 2 diabetic patients.

MATERIAL AND METHODS

A total of 58 patients with type 2 diabetes mellitus and advanced periodontitis who were requiring extraction of all remaining teeth were randomized consecutively into treatment (full-mouth tooth extraction) and control groups (no treatment). Eight patients were lost to follow-up or reported use of antibiotics, leaving 50 patients to be included in the analysis. All patients had all their remaining teeth in a hopeless condition. Relevant data were collected, and glycosylated hemoglobin (HbA(1c) ) and fasting blood glucose levels were measured at baseline and at follow-up times of 3 and 6 mo.

RESULTS

At baseline, the mean (SD) HbA(1c) level was 8.6% (1.24) in the treatment group and 7.7% (0.87) in the control group. In the treatment group, the mean HbA(1c) level decreased significantly from 8.6% at baseline to 7.4% after 3 mo of denture treatment, and continued to decrease to 7.3% after 6 mo. In the control group, the mean HbA(1c) decreased from 7.7% at baseline to 7.5% after 3 mo, and remained almost the same after 6 mo. After adjusting for the baseline HbA(1c) , the mean reduction in HbA(1c) after 3 mo in the treatment group [1.23% (0.79)] was significantly higher than the mean reduction in the control group [0.28% (0.87)].

CONCLUSION

Full-mouth tooth extraction resulted in an improvement in glycemic control among diabetic patients. Large-scale multicentre clinical trials are needed to confirm the current evidence.

Clinical and metabolic changes after conventional treatment of type 2 diabetic patients with chronic periodontitis

BACKGROUND

The aim of this study was to compare the response to conventional periodontal treatment between patients with or without type 2 diabetes mellitus from a clinical and metabolic standpoint.

METHODS

A prospective, parallel, comparative longitudinal clinical study was performed between type 2 diabetics and non-diabetics with moderate generalized chronic periodontitis. The study period was 6 months. Conventional periodontal scaling and root planing were performed, and the response to this treatment was compared between the groups at 3 and 6 months, measuring the plaque index, bleeding on probing, probing depth, level of clinical attachment, and gingival recession. In the diabetic patients, the clinical response was related to measurements of HbA1c and glucose in blood at 3 and 6 months.

RESULTS

An improvement in all clinical variables was observed, with no statistically significant differences between the groups, with the exception of probing depth (P <0.0207). The improvement observed in blood HbA1c levels confirmed a positive metabolic response to periodontal treatment, with a lower value for this variable at each measurement time.

CONCLUSIONS

Both groups of patients showed a clinical improvement after basic non-surgical periodontal treatment. The diabetic patients showed improved metabolic control (lower HbA1c) at 3 and 6 months after periodontal treatment.

Diabetes and periodontal diseases. Committee on Research, Science and Therapy. American Academy of Periodontology

This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office.

Diabetes and periodontal diseases

This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office.

Periodontal findings in elderly patients with non-insulin dependent diabetes mellitus

The periodontal status of 25 patients with non-insulin dependent diabetes mellitus (NIDDM) (age range 58 to 76) was investigated and compared with 40 non-diabetic control subjects (age range 59 to 77). Surfaces with visible plaque and bleeding after probing, calculus, recessions, and pathological pockets were examined. The total attachment loss was calculated as a sum of recessions and pockets in millimeters. Mesial and distal bone loss was measured from panoramic radiographs and mean alveolar bone loss was calculated. Periodontal disease was considered advanced when mean alveolar bone loss was over 50%, or 2 or more teeth had pockets > or = 6 mm. Microbiological analysis comprised the detection of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Bacteroides forsythus by a polymerase chain reaction (PCR) method. Patients with NIDDM had significantly more often advanced periodontitis than control subjects, 40.0% and 12.5%, respectively. Diabetic patients did not harbor more pathogens than the control subjects. The HbA1C level deteriorated in patients with advanced periodontitis, but not in other patients with NIDDM, when compared to the situation 2 to 3 years earlier. Advanced periodontitis seems to be associated with the impairment of the metabolic control in patients with NIDDM, and a regular periodontal surveillance is therefore necessary.

Healing response to non-surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological, and immunologic results

The aim of the present study was to monitor clinical, microbiological, medical, and immunological effects of non-surgical periodontal therapy in diabetics and healthy controls. 20 IDDM (insulin dependent, n = 7) or NIDDM (non-insulin dependent, n = 13) diabetic patients (median duration 11.5 years, range of HbA1C: 4.4-10.6%) with moderate to advanced periodontal disease and 20 matched healthy control patients, were subjected to supragingival pretreatment and subsequent subgingival therapy. Periodontal examinations (API, PBI, BOP, PPD, PAL), microbiological examinations (culture), medical routine examinations, and immunological examinations (oxidative burst response of PMNs to TNF-alpha and FMLP) were performed at baseline, 2 weeks after supragingival, and 4 months after subgingival therapy. 4 months after completion of non-surgical therapy, the following compared to baseline significant (p < or = 0.05) changes (delta) of clinical parameters (median) were found in diabetic patients versus control patients: deltaAPI (30.4% versus 36.3%), deltaPBI (22.9% versus 24.2%), deltaBOP (39.5% versus 46.9%). The median % per patient of pockets with PPD > or = 4 mm decreased from 41.9% to 28.3% in diabetics, and from 41.6% to 31.8% in controls. Microbiologically, similar reductions of periopathogenic bacteria were found in diabetics and controls. Neither periodontal data nor the oxidative burst response of PMNs showed any significant difference (p > 0.05) between diabetics and control patients. In this study, periodontal therapy had no significant influence on medical data of diabetics. In conclusion, this study indicates that metabolically well-controlled diabetics might respond to non-surgical periodontal therapy as well as healthy control patients.

The relationship between clinical periodontal status and insulin-dependent diabetes mellitus. Results after 5 years

The clinical periodontal status of 44 insulin-dependent diabetic children and adolescents and 20 healthy control subjects was compared for a period of approximately 5 years. Fasting blood glucose, fructosamine, and glycosylated hemoglobin (HbA1) values were determined at baseline and 5 years later. The differences in the clinical and laboratory parameters were compared during the study period. The differences between the two groups were also evaluated. The only statistically significant difference observed in the diabetic group was clinical attachment loss (CAL). The CAL was statistically significantly higher in the diabetic group compared to the controls, and a statistically significantly higher in the diabetic group compared to the controls, and a statistically significant positive correlation was observed between the duration of diabetes and CAL. Fructosamine was also correlated with the gingival index in the diabetic group while there was no correlation in the controls. It may be concluded that diabetes modifies the clinical status of the periodontal tissues and increases clinical attachment loss.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

Response to periodontal therapy in diabetics and smokers

Diabetics and smokers are two patient groups at high risk for periodontal disease who also exhibit impaired wound healing and, therefore, constitute two different groups in whom the relationship between host-parasite interaction, outcome of periodontal therapy, and systemic factors is best represented. The results of two independent clinical trials involving treatment of periodontal disease in diabetics and smokers are presented. A new treatment regimen for the management of periodontal disease associated with diabetes mellitus is proposed. This treatment approach incorporates both antimicrobial agents and pharmacological modulation of the host response. Elimination of periodontal infection and reduction of periodontal inflammation in diabetic patients resulted in a significant short-term reduction in the concentration of glycosylated hemoglobin (HbA1c). Control of chronic infections and modulation of the host response offer a new therapeutic approach in the management of patients with both diabetes and periodontal disease. The effect of smoking on periodontal healing is also discussed. The clinical and microbiological response of smokers to non-surgical periodontal therapy is compared to non-smokers. In addition, possible mechanisms whereby diabetes mellitus and cigarette smoking increase the severity of periodontal disease are discussed.

Short-term responses to periodontal therapy in insulin-dependent diabetic patients

This investigation studied relative changes in periodontal conditions of 18 insulin-dependent diabetic patients. Measures of gingival inflammation, crevicular fluid aspartate aminotransferase (AST) levels, probing depth and attachment levels, the presence of three periodontal pathogens (Porphyromonas gingivalis, Bacteroides forsythus, and Actinobacillus actinomycetemcomitans) and serum antibody titers to these bacteria, and blood sugar levels (glycosylated hemoglobin, HbAlc) were studied before and 2 months after non-surgical debridement. Antibody titers to the same bacteria were also studied in sera from 18 sex- and age-matched periodontally healthy and non-diabetic subjects. Periodontal conditions showed significant improvement. The mean probing depth at 4 of the worst sites selected in each patient decreased from 5.7 mm to 4.8 mm (p < 0.0001). The mean full width probing depth changed from 2.9 mm (s.d. +/- 0.2) to 2.5 mm (s.d. +/- 0.3). A mean gain of 0.4 mm attachment level was recorded (P < 0.0001). The mean AST value decreased from 1009 microIU to 518 microIU (P < 0.006). Minimal differences in mean glycosylated hemoglobin values (HbAlc) were noticed before and after treatment. A. actinomycetemcomitans was never detected. P. gingivalis was present at 7% of the sites both before and after treatment. B. forsythus was found at 29% of sites (50% of patients) before and at 36% of sites (61% of patients) after treatment. Positive associations were found between the presence of B. forsythus and AST values, gingival index, probing depth, and attachment level (P < 0.05). Baseline serum IgG titers to P. gingivalis were significantly lower in the patients with diabetes (9.5 ELISA units vs. 28.5 ELISA units in the healthy controls). IgG titers to B. forsythus did not differ between diabetic and non-diabetic subjects. No changes in IgG titers occurred after treatment. Clinical improvements after mechanical non-surgical therapy in patients with insulin-dependent diabetes mellitus were modest after 2 months. Treatment did not eliminate B. forsythus and P. gingivalis and did not affect IgG titer responses. More intense therapy, and longer follow-up times, may be necessary to see more pronounced clinical and systemic effects.

The relationship between clinical attachment loss and the duration of insulin-dependent diabetes mellitus (IDDM) in children and adolescents

The periodontal status of 77 diabetic children and adolescents, and 77 paired, systemically-healthy, sex- and age-matched control subjects, was clinical examined. Fasting blood glucose, fructosamine and glycosylated haemoglobin (HbA1) values were determined. The mean periodontal pocket depths, clinical attachment levels and the parameters to assess diabetes mellitus from the diabetic group were significantly higher than those of the controls. We found a positive correlation between the duration of diabetes and clinical attachment loss, but not with periodontal probing depth, plaque index and gingival index in the diabetic group. A positive correlation was also assessed between the present serum fructosamine and gingival index in the diabetic group, but not in controls.

Serum fructosamine correlates with gingival index in children with insulin-dependent diabetes mellitus (IDDM)

Fructosamine assay, which is used in diagnosing and monitoring diabetic patients, is compared with the hemoglobin and plasma glucose assays in children and adolescent insulin-dependent diabetes mellitus patients. We demonstrated that the gingival index scores were correlated with fructosamine values in insulin-dependent diabetes mellitus patients but not in non-diabetic controls. We also found that there was no correlation between gingivitis scores and fasting plasma glucose and HbA1c values. Periodontitis was found to be rare in diabetic children and adolescents.

Fructosamine as a possible monitoring parameter in non-insulin dependent diabetes mellitus patients with periodontal disease

Fructosamine assay is a new test used in the diagnosis and monitoring of diabetic patients. This assay may be of interest to the periodontist for, while the traditional plasma glucose value would give a general view and information about diabetic control at a certain point, the fructosamine concentration gives an indication of the plasma glucose level over a considerable period of time, such as 1 to 3 weeks. We investigated whether there was any relation between the diseased state of the periodontal tissues and plasma fructosamine and the plasma glucose values in non-insulin dependent diabetes mellitus (NIDDM) patients. We found that fructosamine correlated with the degree of gingival bleeding, however serum glucose levels had little or no correlation.