|Year : 2020 | Volume
| Issue : 4 | Page : 159-164
The impact of chronic periodontitis on glycemic control and serum lipids in comparison with periodontal health
R Mathangi1, Bagavadgita Jayaraman2, Nagarajan Geethapriya3, Alagarsamy Venkatesh3, Shila Samuel4
1 Research and Development Centre, Bharathiar University, Coimbatore; Department of Biochemistry, Sree Balaji Dental College and Hospital, Bharath University, BIHER, Chennai, Tamil Nadu, India
2 Department of Periodontics, Bharath University, BIHER, Chennai, Tamil Nadu, India
3 Department of Conservative Dentistry and Endodontics, Bharath University, BIHER, Chennai, Tamil Nadu, India
4 Department of Biochemistry, VRRIBMS (Affiliated to University of Madras), Chennai, Tamil Nadu, India
|Date of Submission||10-Sep-2020|
|Date of Decision||15-Sep-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||30-Nov-2020|
VRRIBMS, Chennai - 600 056, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Context: Periodontitis is a chronic inflammatory oral disease. The inflammatory cytokines that are released as a consequence of periodontal inflammation has wide spread systemic effects on glycemic control and lipid profile of healthy controls. Aim: The study aims to study the impact of chronic periodontitis (CP) on glycemic control and serum lipids in comparison with periodontal health. Materials and Methods: This study is designed as hospital-based cross-sectional study. Fifty healthy controls and 50 CP subjects were included in the study. Complete information about demographic variables, glycemic control, and serum lipid profile were collected. Statistical Analysis: Statistical expressions were determined using Student's t-test, Chi-square test, and Pearson correlation coefficient. Results: Serum lipid profile and glycated hemoglobin levels were abberated in CP. Conclusion: CP influences glycemic control and induces dyslipidemia in individuals who are otherwise healthy without any systemic illness.
Keywords: Chronic periodontitis, glycated hemoglobin, lipid profile
|How to cite this article:|
Mathangi R, Jayaraman B, Geethapriya N, Venkatesh A, Samuel S. The impact of chronic periodontitis on glycemic control and serum lipids in comparison with periodontal health. J Dent Res Rev 2020;7:159-64
|How to cite this URL:|
Mathangi R, Jayaraman B, Geethapriya N, Venkatesh A, Samuel S. The impact of chronic periodontitis on glycemic control and serum lipids in comparison with periodontal health. J Dent Res Rev [serial online] 2020 [cited 2021 Apr 14];7:159-64. Available from: https://www.jdrr.org/text.asp?2020/7/4/159/302046
| Introduction|| |
Periodontitis is the most prevalent immunoinflammatory oral disease. Chronic periodontitis (CP) is characterized by gingival inflammation, loss of tooth supporting connective tissue, alveolar bone loss, and eventually loss of tooth.
Periodontitis is prevalent across all age groups worldwide. The prevalence of CP in middle aged adults is around 15%–20% globally, with Asians having third highest prevalence. In India, the prevalence is 89.6% and 79.9% among those aged 35–44 and 65–74 years, respectively. A study by Chandra et al. predicts prevalence of periodontitis of up to 95% in Indians. The prevalence of periodontitis in India was predicted to be more than 300 million in 2015 by Shah in her report for the National Commission on Macroeconomics and Health. However, there is lack of complete epidemiological data regarding the prevalence of periodontitis in India.
The primary etiological factor for periodontitis is bacterial infection. Host immune inflammatory reactions that are elicited following the bacterial infection results in continuous release of pro inflammatory cytokines such as interleukin (IL) 6, tumor necrosis factor α (TNF-α). These cytokines move beyond the local environment of periodontium and cause systemic changes contributing to poor glycemic control and dyslipidemia,, in systemically healthy individuals.
The over production of IL6 and TNF alpha also ameliorate insulin resistance by altering cell signaling through nuclear factorkappa B (NFκB) pathway and C-Jun N terminal kinases axes. The alterations in NFκB pathway also increases osteoclastogenesis through RANK-RANKL signaling pathway leading to alveolar bone loss and also decreases osteogenesis.
CP is a risk factor for both diabetes and hyperlipidemia., The presence of severe periodontitis is associated with 19%–33% higher risk of developing diabetes compared to people who are periodontally healthy.
Periodontitis and diabetes mellitus are said to have a bidirectional relationship with large numbers of studies supporting the negative influence of CP in glycemic control.
Dyslipidemia characterizes abnormalities in the serum levels of total cholesterol (TC), low density lipoprotein (LDL), very low-density lipoprotein (VLDL), and triglycerides (TG) with increase in aforementioned values and decrease in high-density lipoprotein (HDL). Imbalance in serum lipids results in atherosclerosis which forms the pathological basis for cardiovascular diseases.
Like diabetes, CP and dyslipidemia is also reported to have a two way relationship, with CP, that is, dyslipidemia increasing the risk of periodontitis and periodontitis mediated inflammatory cytokines increasing serum lipid levels.,
Many recent studies have also shown positive relationship between CP, hyperlipidemia, and cardiovascular diseases.,, The effect of periodontal inflammation on glycemic control and serum lipids heightens the risk of systemic diseases such as type 2 diabetes and cardiovascular disease. However, the mechanism by which periodontitis influences systemic diseases is not completely understood.
This study hypothesizes that CP influences glycemic control, serum lipids, and periodontal parameters in systemically healthy individuals. This study evaluated the impact of CP on glycemic control and dyslipidemia in comparison with individuals who are periodontally and systemically healthy.
| Materials and Methods|| |
Study design and participants
The study is designed as a cross-sectional study. The study was approved by Institutional Ethical Committee of Sree Balaji Dental College, BIHER, Chennai (No. SBDCECM104/01/15/04) and written consent was obtained from the participating subjects according to the Indian Council of Medical Research and World Medical Association Declaration of Helsinki guidelines at the time of sample collection.
The study samples were recruited from patients seeking dental care from the Department of Periodontology, SBDCH, BIHER, Chennai, India. One hundred study subjects were included in this study and categorized into two groups:
- Group I (n = 50) – Healthy controls
- Group II (n = 50) – Subjects with severe CP.
Inclusion and exclusion criteria
Subjects in the age group between 25 and 55 years were included in the study. The glycemic status was confirmed by measuring fasting blood sugar and postprandial blood sugar (FBS and PPBS). Levels of glycated hemoglobin (HbA1c) measured to understand glycemic control. The status of periodontitis was assessed using periodontal probing depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP). Pregnant women, smokers, subjects on bone remodeling drugs such as bisphosphonates, nonsteroidal anti-inflammatory drugs, antibiotic therapy in the past 3 months or any other periodontal therapy in the past 6 months were excluded from the study. Subjects with other systemic diseases, such as Type 2 diabetes, family history of hyperlipidemia which would have effect on progression of periodontitis were excluded from the study. Information related to medical and dental history was obtained through a questionnaire.
Screening for periodontitis
All subjects were given a clinical periodontal examination to determine PPD and attachment level for each tooth (CAL), presence of calculus, BOP, assessment of plaque using Silness and Loe plaque index.
Biochemical parameters for glycemic control and lipid profile
Biochemical measurements for glycemic control such as fasting, postprandial glucose levels HbA1c, and serum lipid profile were assessed using blood sample obtained from subjects. Venous blood samples were collected after an overnight fast. HbA1c was measured using high-performance liquid chromatography method, FBS, PPBS, TC, VLDL, HDL, TG were measured by enzymatic method. LDL was calculated using Friedewald formula.
All statistical analysis was performed with the help of Statistical package for the social sciences.(Chicago, IL:USA:IBM corp.) 20.0. Statistical expressions were determined using Student's t-test. Gender relationship between groups was analyzed statistically using Chi-square test. Pearson correlation coefficient was calculated to assess the relationship levels. P < 0.05 was considered to be significant statistically.
| Results|| |
This study included 50 systemically and gingivally healthy individuals and 50 individuals with CP.
[Table 1] represents the demographic values in the study groups. The mean age was 31.52 ± 6.345 years in healthy controls as compared to 50.12 ± 5.83 years in CP. The mean age was much higher in CP and showed a greater statistical significance (P < 0.001). Gender and income of the subjects did not show any statistical significance among groups.
[Table 2] represents the clinical periodontal parameters. CAL was found to be nil in healthy controls whereas attachment loss was very highly statistically significant in CP (P < 0.0001). Differences in percentage of BOP % were evident in CP when compared to Healthy controls (HC) (P < 0.0001). Likewise, PPD was also found to be increased in CP than HC, with mean ± standard deviation (SD) values of 5.90 ± 0.71. The relationship was found to be very highly significant (P < 0.0001).
[Table 3] represents the biochemical parameters of glycemic control. The mean ± SD values of FBS (mg/dL) were much similar in HC (93.50 ± 6.458) and CP (94.35 ± 8.054) and did not show any statistical significance. However, the PPBS levels were found to be higher in CP with mean ± SD of 120.48 ± 8.431, than healthy controls with mean ± SD of 115.81 ± 8.154, showing a clear statistical significance (P < 0.03).
HbA1C levels were found to be significantly elevated (P < 0.001) in CP as compared to HC, while the HbA1c levels were normal in HC.
[Table 4] represents serum lipid profile. The mean ± SD levels of TC, VLDL, LDL were higher in CP than HC. The P value for TC, VLDL, LDL was found to be very highly statistically significant. The HDL levels were higher in HC (54.07 ± 5.3) than CP (52 ± 6.2). However, the TC/HDL ratio did not show any statistical significance between groups.
[Table 5] represents the correlation between HbA1c levels and periodontal parameters, FBS, and PP sugar levels.
|Table 5: Pearson correlation of glycosylated hemoglobin with periodontal parameters and biochemical parameters of glycemic control in chronic periodontitis|
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HbA1c showed a positive correlation with CAL, BOP, PPD. However, the P values were nonsignificant. HbA1c showed significant positive correlation with postprandial sugar levels (P < 0.002).
[Table 6] represents the correlation between age of CP with glycemic control and periodontal parameters.
|Table 6: Pearson correlation of age with periodontal parameters and biochemical parameters of glycemic control in chronic periodontitis|
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Age of the CP subjects showed a positive correlation with CAL, BOP, PPBS. The correlation between age and HbA1c was statistically significant (P < 0.002).
| Discussion|| |
CP is the most prevalent oral disease and is the leading cause for tooth loss across the globe. A large number of studies have reported the influence of diabetes and dyslipidemia on periodontal health. However, in this study, we have outlined the converse relationship of impact of periodontitis on glycemic control and lipid profile.
This study assessed the relationship between age, gender, and socioeconomic status on periodontal health.
This clinical study shows age as a significant risk factor of periodontitis. Several studies have shown that increase in age increases the risk and severity of periodontitis.,, A study Billings et al., Jevon et al., supports proportionate increase in severity of periodontitis with age. However, this finding adds further significance to the existing literature as mean age was only 50.12 years, representing middle age group.
This study is not gender matched. However, gender did not show any significant difference as the ratio of male and female participants in both the study groups were more or less similar. Socioeconomic status and education play a significant role in the maintenance of oral health. Here, the study subjects were well above the poverty line and the monthly income did not show any significant difference between groups.
The clinical periodontal parameters such as BOP, CAL, and PP showed a statistically significant expression in CP, indicating periodontal inflammation and loss of tooth supporting structure. The FBS levels, in our study, did not show much variation between the study groups. The PPBS levels were significantly high in CP however much within normal limits.
Our study shows increase in mean HbA1c values in CP predicting a prediabetes like condition. This is consistent with studies of Rajan et al. and Saxena and Deepika suggesting a link between periodontitis in influencing glycemic control among nondiabetics in Indian population. Our study is also in agreement with findings of Vadakkekuttical et al. which shows prediabetic levels of HbA1c under periodontal inflammation.
HbA1c is an indicator of blood glucose concentration on an average for 2–3 months. and used as gold standard for measuring hyperglycemia and glycemic control. However, FBG and PP are the most preferred way of measuring glycemic control as it is cost-effective.
While FBG represent overall diurnal hyperglycemia in poor glycemic control,, postprandial sugar levels contributes more to glycemic control than FBG. Control of postprandial sugar levels was found to be important to decrease or maintain HbA1c levels.
There is paucity in available literature regarding the influence of periodontitis with dysglycemic status especially with postprandial sugar levels. A large number of studies have related periodontitis to worsening of glycemic status in diabetes or vice versa. Equal number of studies has discussed the role of interventional periodontal therapy in improvement of glycemic status.
A study by Choi et al. has shown impairment in FBS level in periodontitis with respect to CAL and Pocket depth. Wolff et al. have reported varying HbA1c levels in periodontitis. A study by Kalsi et al. also confirms impaired glycemic control in chromic periodontitis. A study by Naseralavi et al. also shows increased HbA1c levels in nondiabetics and reduction in levels following periodontal treatment. A study by Kowall et al. differs with study in suggesting that periodontitis is not associate with prediabetes condition.
The Pearson correlation coefficient has shown a positive correlation between HbA1c and postprandial sugar levels in CP subjects, indicating that there exist a pragmatic relation between HbA1c levels and PP sugar levels. This is an important finding as many studies across the world are trying to identify a surrogate marker for HbA1c, for early detection and maintenance of glycemic control.
The Pearson correlation of HbA1c with periodontal parameters showed a positive relationship, indicating the influence of glycemic control on aberrant periodontal parameters such as CAL, BOP, and PPD.
Furthermore, the significant increase in HbA1c levels and also FBS and PP in CP in comparison with healthy controls add strength to the view that periodontitis induces aberrant glycemic control in systemically healthy controls.
Inflammation associated with periodontitis is a risk factor for dyslipidemia. In this study, an increase in serum level of TC, VLDL, and LDL were found in CP when compared with healthy controls [Graph 1].
Recent studies by Sharma et al. and Sandi et al. also reinforce the effects of serum dyslipidemia in adverse periodontal health. A study by Thapa and Wei. also describes a significant association between borderline to high level of serum TC and periodontitis. Lee et al. have reported significant association between periodontitis and low HDL and high LDL cholesterol levels in Korean women in a nationwide study conducted among 6095 individuals. A meta-analysis by Nepomuceno et al. have also confirmed increasing the levels of TC, VLDL, and LDL and decreasing the levels of HDL in periodontitis.
Smoking and diabetes are the two major modifiable risk factors of periodontitis. The strength of this study is exclusion of smokers and diabetics, limiting confounding errors due to the influence of smoking and diabetes in CP and glycemic control. The probable weakness of this study is lesser sample size.
Further studies with larger sample size and interventional studies involving periodontal therapy are needed to establish whether periodontal therapy can improve prediabetic state in periodontitis.
| Conclusion|| |
From the results of this study, it could be concluded that CP has a significant influence in glycemic control and lipid profile in systemically healthy individuals. Increase in age is a significant risk factor in increasing the severity of CP.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]