Oral health and glycosylated hemoglobin among type 1 diabetes children in South India

K Vidya; Prakashchandra Shetty; Latha Anandakrishna

doi:10.4103/JISPPD.JISPPD_330_16



ORIGINAL ARTICLE

Year : 2018 \| Volume : 36 \| Issue : 1 \| Page : 38-42

Oral health and glycosylated hemoglobin among type 1 diabetes children in South India

K Vidya, Prakashchandra Shetty, Latha Anandakrishna
Department of Pediatric and Preventive Dentistry, M. S. Ramaiah Dental College and Hospital, Bengaluru, Karnataka, India

Date of Web Publication

28-Mar-2018

Correspondence Address:
Dr. K Vidya
Flat #103, Jayalakshmi Residency, 1^st Main, 1^st A Cross, T. Krishnareddy Layout, Banaswadi, Bengaluru - 560 043, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/JISPPD.JISPPD_330_16

Abstract

Background: The study was an attempt to evaluate the relationship between oral health status and the level of glycemic control in type 1 diabetes patients. Methods: The study was carried out in 87 children with type 1 diabetes, aged 8–16 years, attending a diabetes specialty hospital. The oral health of these patients was measured using the WHO 1997 Oral Health Survey criteria for diagnosis of dental caries, gingival index, and plaque index. Samples were then divided into two groups as controlled (≤6.99% glycosylated hemoglobin [HbA1c]) and uncontrolled (≥7% HbA1c) diabetes as per the guidelines for glycemic control in diabetics given by the American Diabetes Association. The oral health between the groups was compared. Results: Data were statistically analyzed using student t-test. Results showed a significant difference in decayed, missing, and filled surface component (P = 0.043) and gingival index scores (P< 0.001) in the permanent dentition between controlled and uncontrolled groups but not in case of the primary dentition. Conclusions: The data findings suggest that metabolic control had an impact on caries prevalence and gingival health of these patients, in case of permanent dentition. As the glycemic control became poorer, the caries prevalence and gingival inflammation increased. When primary dentition was taken into consideration, the correlation was not significant.

Keywords: Dental caries, diabetes, gingival health, glycosylated hemoglobin

How to cite this article:
Vidya K, Shetty P, Anandakrishna L. Oral health and glycosylated hemoglobin among type 1 diabetes children in South India. J Indian Soc Pedod Prev Dent 2018;36:38-42

How to cite this URL:
Vidya K, Shetty P, Anandakrishna L. Oral health and glycosylated hemoglobin among type 1 diabetes children in South India. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2021 Jan 16];36:38-42. Available from: https://www.jisppd.com/text.asp?2018/36/1/38/228748

Introduction

Diabetes mellitus (DM) is a chronic systemic metabolic disease characterized by abnormally high blood glucose levels.^[1] The International Diabetes Federation (IDF) estimates the total number of diabetic participants to be around 40.9 million in India, and this is further set to rise to 69.9 million by the year 2025.^[2]

The onset of type 1 DM occurs predominantly in childhood, with median age of 7–15 years, but may present at any age.^[3] Oral manifestations of diabetes are mainly related to fluid imbalance, an altered response to infection, possible increased glucose concentrations in saliva, and microvascular changes.^[4] Studies have shown high ratio of gingival inflammation and periodontal diseases with subsequent loss of teeth in diabetic patients, and the degree of inflammation and caries incidence depends on the metabolic control.^{[1],[5],[6],[7]}

For decades, the diagnosis of diabetes was based on plasma glucose criteria, either the fasting plasma glucose or the 2 hour value in the 75-g oral glucose tolerance test.^[7] In 2009, an International Expert Committee that included representatives of the American Diabetes Association (ADA), the IDF, and the European Association for the Study of Diabetes recommended the use of the A1c (glycosylated hemoglobin, [HbA1c]) test to diagnose diabetes, with a threshold of ≥6.5%, and ADA adopted this criterion in 2010.^[8],[9]

The purpose of the study was to find the relation between the oral health status (caries experience and degree of gingival inflammation) and the level of glycemic control in type 1 DM patients.

Methods

Sample size was calculated ^[7] to be 70 so as to achieve 90% power, which has a significance level of 0.05. A tertiary care hospital providing services for patients with DM from various parts of South India was the source for study participants. Selection of study participants was done using convenience (nonrandom) sampling technique. This cross-sectional study was carried out among 87 children with type 1 diabetes, aged 8–16 years of both genders. Permission was obtained from the hospital authority to conduct the study in the hospital, and informed consent was obtained from the parents/guardians. Ethical clearance for the study was obtained from the institutional review board.

Patients with the history of having diabetes for 2 years and above were included in the study. Participants having type 1 DM associated with other syndromes or if the disease was due to underlying systemic disorders or drugs were excluded from the study.

A brief case history of the patients was recorded. Examination was performed by seating the patients on an ordinary chair, under natural light, using sterile portable equipment which included mouth mirror, CPITNC probe, two-tone plaque disclosing agents, and applicator tips. During the visits, the children were accompanied by their parents/caretakers, and the oral health status of these patients was measured using following indices:

The WHO 1997 Oral Health Survey criteria for diagnosis of dental caries decayed, missing, and filled surfaces/decayed and filled surfaces (DMFS/dfs index)
Gingival index given by Loe H and Silness J (1963)
Plaque index given by SilnessPand Loe H (1964).

For primary dentition,criteria given by Loe and Silness were used to record gingival health for all primary teeth with no preshedding mobility while criteria given by Silness and Loe were used to measure the plaque.

Blood samples were collected in the hospital by the laboratory technician, and HbA1c values measured (turbidimetric immunoassay method) were recorded on the same day of examination. Then, the participants were divided into two groups as controlled diabetes group (≤6.99% HbA1c) and uncontrolled diabetes group (≥7% HbA1c) as per the guidelines for glycemic control in diabetics given by ADA. The data were subjected to statistical analysis.

Statistical analysis

All data were processed by SPSS software (10.5, SPSS Inc., Chicago IL, USA). As the data were in multiples, it was first log transformed. The results were averaged (mean ± standard deviation) for continuous data. Student's t-test was used to determine whether there was a statistical difference between the two groups in the parameters measured. For the test that was used, P < 0.05 was taken to be statistically significant.

Results

A total of 87 children with type 1 DM were included in the study [Table 1]. Out of which, 21.8% (n = 19) had controlled diabetes and 78.2% (n = 68) had uncontrolled diabetes. The mean age group of children with controlled diabetes was 12.89 ± 2.6 years and uncontrolled diabetes 13.04 ± 2.4 years, and there was no significant difference in mean age between the groups [Table 2]. [Table 3] shows distribution of the study groups according to gender. Statistically significant association was found between gender and diabetic control. Five males (26.3%) and 14 females (73.7%) had controlled diabetes whereas 38 males (55.9%) and 30 females (44.1%) had uncontrolled diabetes.

Table 1: Distribution of types of diabetics (n=87)

Click here to view

Table 2: Mean age distribution of the study groups

Click here to view

Table 3: Distribution of the study groups according to gender

Click here to view

Significantly higher DMFS and gingival index scores were observed in the uncontrolled group when compared to the controlled group (P = 0.043 and P < 0.001, respectively), but there was no significant difference in terms of plaque scores in the permanent dentition between the groups (P = 0.164) as shown in [Table 4] [Figure 1]. When the primary dentition was considered, there was no significant difference in dfs (P = 0.184), plaque (P = 0.872), and gingival scores (P = 0.179) between the groups [Table 5] and [Figure 2].

Table 4: Distribution of decayed, missing, or filled surface, plaque, and gingival scores of permanent dentition between the study groups

Click here to view

Figure 1: Distribution of DMFS, plaque and gingival scores of permanent dentition between the study groups

Click here to view

Table 5: Distribution of decayed and filled surface, plaque, and gingival scores of primary dentition between the study groups

Click here to view

Figure 2: Distribution of dfs, plaque and gingival scores of primary dentition between the study groups

Click here to view

Discussion

DM may have profound oral effects, and the dentist is often the first health-care provider to encounter an individual with undiagnosed or untreated disease. The oral symptoms are believed to occur more quickly and more severe in uncontrolled type 1 DM compared to uncontrolled type 2 DM.^[10]

The chief purpose of this study was to find the metabolic control of type 1 DM patients and its relation with caries and gingival health of the participants. Out of 87 participants included in the study, only 21.8% had controlled diabetes and rest of the participants (78.2%) had uncontrolled diabetes. The possible reason for this difference could be that children frequently become careless in adhering to the dietary regimen as the disease progresses, and also, an early age of onset is said to be associated with greater severity (thereby rendering control more difficult).^[11] Since both dental caries and gingivitis are chronic diseases, to find the effect of metabolic control on these two factors, participants with minimum 2-year duration of diabetes were selected for the study. Since there are very minimal studies done to correlate the metabolic control with dental caries and gingival health of type 1 diabetic patients in mixed dentition,^{[5],[6],[7],[12]} age group selected for the study was 8–16 years (mixed dentition). Age group selected also encompasses the period where hormonal changes influence the oral health due to pubertal changes. However, criteria of age were same for both the groups, and the influence of hormone on a particular group may not be considered significant.

Regarding the association between gender and diabetic control, females had more controlled diabetes (73.7%) and males had more uncontrolled diabetes (55.9%). This could be due to the differences in the lifestyles of male and female adolescents. In a study, results have shown consumption of fast food, alcohol and smoking habits were more prevalent in adolescent males compared to adolescent females.^[13] In contrast to the present study, a study done by Valle et al. showed no gender difference in the HbA1c levels of type 1 diabetic patients.^[14] In our study, statistically significant difference was observed in DMFS component (P = 0.043) and gingival index scores (P< 0.001) in the permanent dentition between controlled and uncontrolled groups. As such incidence of periodontitis increases among diabetics after puberty and as the patient age increases, although plaque periodontopathogens remain the same.^{[15],[16],[17],[18],[19],[20]} Also periodontal disease usually starts at puberty as mild gingivitis with bleeding and gingival recession; and later it may develop into severe periodontitis especially in children with poor control of diabetes.^[21] Since the age group selected in our study was between 8 and 16 years; we considered gingival health instead of periodontal health. However, there was no significant difference in terms of plaque scores (P = 0.164) between the groups, which supports the concept that poor metabolic balance is associated with and predisposes to gingival inflammation and dental caries in diabetic patients.^[5],[6]

In our study, higher mean DMFS values were observed in uncontrolled participants compared to controlled participants, which is in agreement with earlier reports by Twetman et al. and Karjalainen et al.^[6],[7],[22] The findings can to a certain extent be explained by the fact that excess glucose enters into the oral cavity through the saliva and gingival crevicular fluid in metabolically unbalanced cases.^[23] High values of HbA1c, especially in the long run, indicate that the participants concerned have had periods of hyperglycemia during which salivary flow may have decreased, and salivary glucose concentrations may have risen, thereby increasing their caries risk. Furthermore, the role of behavior should not be forgotten because poor control may be a result of negligence in relation to diabetes care and treatment regimens, and such participants may be liable to be careless about their dental health and dental care as well. High salivary or gingival fluid glucose concentrations and decreased salivary flow rates have been reported especially if diabetes is poorly controlled.^[6] Our study showed an established relationship between glucose balance and gingival inflammation which is in accordance with the studies by Karjalainen and Knuuttila and Lal et al.^[5],[12] Poor control of diabetes increases the risk of inflammation and delays wound healing in many different ways. Hyperglycemia has been found to decrease polymorphonuclear cell chemotaxis, phagocytosis, and intracellular killing.^[24],[25] The ability of HbA1c to carry oxygen is impaired, decreasing tissue oxygenation. Hyperglycemia induces blood flow abnormalities, including increased blood viscosity, reduced erythrocyte deformability, and increased platelet aggregation, which further enhance tissue hypoxia.^[26],[27] Increased platelet aggregation is accompanied by increased release of serotonin and lysosomal enzymes, potentiating inflammatory reactions. Changes in the permeability of small vessels, especially because of thickened basement membranes as diabetes persists, impair tissue metabolism and inflammatory cell influx to the site of infection. In the long run, changes in collagen metabolism and composition may also alter host response. These alterations are corrected to normal or near normal once poor glucose control is corrected.^[24],[25]

In the present study, there was no statistically significant difference in dfs (P = 0.184), plaque (P = 0.872), and gingival scores (P = 0.179) in the primary dentition between the study groups. However, Lal et al. reported in their study that diabetic children had significantly high gingival bleeding than controls for both primary and permanent teeth. The number of teeth with bleeding had a significant association with mean HbA1c, body mass index, and duration of diabetes.^[12]

The advantages of using HbA1c over routine blood sugar levels is that children frequently become careless in adhering to the dietary regimen as the disease progresses and the routine blood sugar levels are highly subjected to diet variations and hence may lead to variations in blood glucose levels.^[11] Long-term blood glucose profiles of patients require the collection of multiple blood samples, which in turn requires multiple pricks. Whereas measuring HbA1c gives feedback on the glycemic control of previous 2-3 months. HbA1c levels can be easily and conventionally determined from a single blood sample and hence is preferred.^[28]

In the present study, only the most common infectious dental diseases such as dental caries and gingivitis were considered. The frequency of occurrence of other soft-tissue lesions such as aphthous stomatitis, angular cheilitis, candidiasis and lichen planus and developmental defects of teeth and their relation with the metabolic control can be considered in the future study.

Conclusions

In our study, it was observed that hyperglycemia and poor metabolic control of diabetes increased gingival inflammation and dental caries. Furthermore, achieving good glycemic control is difficult even though not impossible. Although not all gingivitis proceeds into a destructive periodontal disease, lowered resistance toward plaque in poorly controlled children and adolescent diabetics indicates that many biological alterations may have taken place during poor metabolic control. Hence, the prevention of plaque-induced gingivitis is very important. As dental caries can be prevented by various in-office and at-home preventive measures, the uncontrolled diabetic patients would likely benefit from fluoride supplements, pit and fissure sealants, and meticulous plaque control, which require mutual and consistent efforts from both the patients and their health-care professionals.

Acknowledgement

I would like to acknowledge Dr. Dhananjaya, Dr. Ashmitha, and Dr. Girish, M. S. Ramaiah Dental College and Hospital, as well as Dr. Prasannakumar, Dr. Sanjay Reddy, and Mr. DhilipShetty, Bangalore Diabetes Hospital, for their immense support during the study and Mr. Jagannath, for providing statistical support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Orbak R, Simsek S, Orbak Z, Kavrut F, Colak M. The influence of type-1 diabetes mellitus on dentition and oral health in children and adolescents. Yonsei Med J 2008;49:357-65.
2.	Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30. [PUBMED] [Full text]
3.	Alves C, Brandão M, Andion J, Menezes R. Oral health knowledge and habits in children with type 1 diabetes mellitus. Braz Dent J 2009;20:70-3.
4.	Welbury RR, Duggal MS, Hosey MT. Pediatric Dentistry. 3^rd ed. New York, United States: Oxford Publishers; 2006. p. 405-6.
5.	Karjalainen KM, Knuuttila ML. The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1996;23:1060-7.
6.	Karjalainen KM, Knuuttila ML, Käär ML. Relationship between caries and level of metabolic balance in children and adolescents with insulin-dependent diabetes mellitus. Caries Res 1997;31:13-8.
7.	Twetman S, Johansson I, Birkhed D, Nederfors T. Caries incidence in young type 1 diabetes mellitus patients in relation to metabolic control and caries-associated risk factors. Caries Res 2002;36:31-5.
8.	American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33 Suppl 1:S62-9.
9.	International Expert Committee. International expert committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-34.
10.	Atkinson MA, Maclaren NK. What causes diabetes? Sci Am 1990;263:62-3, 66-71.
11.	Ziskin DE, Siegel EH, Loughlin WC. Diabetes in relation to certain oral and systemic problems: Part 1: Clinical study of dental caries, tooth eruption, gingival changes, growth phenomena and related observations in juveniles. J Dent Res 1944;23:317-31.
12.	Lal S, Cheng B, Kaplan S, Softness B, Greenberg E, Goland RS, et al. Gingival bleeding in 6- to 13-year-old children with diabetes mellitus. Pediatr Dent 2007;29:426-30.
13.	Singh AK, Maheshwari A, Sharma N, Anand K. Lifestyle associated risk factors in adolescents. Indian J Pediatr 2006;73:901-6.
14.	Valle T, Koivisto VA, Reunanen A, Kangas T, Rissanen A. Glycemic control in patients with diabetes in Finland. Diabetes Care 1999;22:575-9.
15.	Cianciola LJ, Park BH, Bruck E, Mosovich L, Genco RJ. Prevalence of periodontal disease in insulin-dependent diabetes mellitus (juvenile diabetes). J Am Dent Assoc 1982;104:653-60.
16.	de Pommereau V, Dargent-Paré C, Robert JJ, Brion M. Periodontal status in insulin-dependent diabetic adolescents. J Clin Periodontol 1992;19:628-32.
17.	Ervasti T, Knuuttila M, Pohjamo L, Haukipuro K. Relation between control of diabetes and gingival bleeding. J Periodontol 1985;56:154-7.
18.	Gusberti FA, Syed SA, Bacon G, Grossman N, Loesche WJ. Puberty gingivitis in insulin-dependent diabetic children. I. Cross-sectional observations. J Periodontol 1983;54:714-20.
19.	Novaes AB Jr., Pereira AL, de Moraes N, Novaes AB. Manifestations of insulin-dependent diabetes mellitus in the periodontium of young Brazilian patients. J Periodontol 1991;62:116-22.
20.	Seppälä B, Seppälä M, Ainamo J. A longitudinal study on insulin-dependent diabetes mellitus and periodontal disease. J Clin Periodontol 1993;20:161-5.
21.	Iughetti L, Marino R, Bertolani MF, Bernasconi S. Oral health in children and adolescents with IDDM – A review. J Pediatr Endocrinol Metab 1999;12:603-10.
22.	Twetman S, Nederfors T, Stahl B, Aronson S. Two-year longitudinal observations of salivary status and dental caries in children with insulin-dependent diabetes mellitus. Pediatr Dent 1992;14:184-8.
23.	Reuterving CO, Reuterving G, Hägg E, Ericson T. Salivary flow rate and salivary glucose concentration in patients with diabetes mellitus influence of severity of diabetes. Diabete Metab 1987;13:457-62.
24.	Morain WD, Colen LB. Wound healing in diabetes mellitus. Clin Plast Surg 1990;17:493-501.
25.	Rosenberg CS. Wound healing in the patient with diabetes mellitus. Nurs Clin North Am 1990;25:247-61.
26.	McMillan DE, Utterback NG, La Puma J. Reduced erythrocyte deformability in diabetes. Diabetes 1978;27:895-901.
27.	Kawamura K, Dohl T, Tamai K, Shirakawa M, Okamoto H, Tsujimoto A, et al. Gingival tissue-produced inhibition of platelet aggregation and the loss of inhibition in streptozotocin-induced diabetic rats. J Periodontal Res 1988;23:87-90.
28.	McCarter RJ, Hempe JM, Chalew SA. Mean blood glucose and biological variation have greater influence on hbA1c levels than glucose instability: An analysis of data from the diabetes control and complications trial. Diabetes Care 2006;29:352-5.