10285
Study to Evaluate the Level of Awareness about the Association between Diabetes and Periodontal Health in Diabetic Individuals - A Questionnaire
Based Study.
Dr. R. Hemalatha MDS1, Dr. V.Vidyashree Nandini MDS, DNB2, Dr.A. Aniz MDS3
1Professor, Dept of Periodontics
KarpagaVinayagaInstitute of DentalSciences, Chinnakolambakkam,
MaduranthangamTaluk, ChengalpetDt.
2Professor and HOD, Dept of Prosthodontics
SRM Kattankulathur Dental College and Hospital SRM Institute of Science and Technology Potheri, Kattankulathur Campus, 603203
3Professor and HOD, Dept of Periodontics
KarpagaVinayaga Institute of Dental Sciences Chinnakolambakkam,
MaduranthangamTaluk, ChengalpetDt.
Corresponding Author:
Dr. V.Vidyashree Nandini MDS, DNB Professor and HOD,Dept of Prosthodontics
SRM Dental college, Kattankulathur, Chengalpet Dt.
E mail: [email protected] Abstract:
Introduction: Diabetes Mellitus is a metabolic disorder characterized by decreased insulin secretion, action or a combination of both, resulting in hyperglycemia and excretion of glucose in urine. Oral disease is one of the complications of Diabetes Mellitus that is less emphasized and discussed with patients by a Physician or Diabetologist. The hyperglycemia in Diabetes Mellitus exaggerates the destruction of periodontal tissues, which in turn has negative influence on glycemic control. Periodontitis has been shown to adversely affect glycemic control in Diabetic patients, thereby increasing the risk to develop diabetic complications. Periodontal treatment seems to effectively improve the glycemic control of individual. Various researches have shown adverse bidirectional relationship between Diabetes Mellitus and Periodontal Disease. Aim and Objectives of the study: To assess 1)The level of knowledge and awareness in Diabetic patients about the systemic and oral complications following Diabetes Mellitus 2)Knowledge about the
type of diabetes. 3) Percentage of Physicians advising frequent dental consutation for their diabetic patients. 4) Awareness in Diabetic individuals about the need to perform better oral care to maintain a good oral health than Non-Diabetics. Materials and Methods: A total number of 150 Diabetic patients were included in the study. The study incorporated the use of a self- administered questionnaire. The pattern of questions in the questionnaire were close-ended (multiple choice questions). The choices in the response of few of the questions were Yes, No, I don’t know. After the participants’ completion of the questionnaire, they were counselled about the importance of regular and routine visit to Diabetologist as part of diabetes care management and the possible correlations between Diabetes and oral health and the importance of maintaining a good oral health and the need for frequent dental visits. Results: Regarding Diabetic patient’s knowledge and awareness about systemic and oral complications associated with Diabetes, 86.7% of patients were aware of their increased risk of heart disease, kidney disease (80.7%), eye disease (61.3%), oral infections(37.3%). About 52.03% had Type II Diabetes, 8.78% had type I Diabetes, 39.19% did not know what type of Diabetes they had. While addressing the question about the percentage of Physicians advising the need for frequent dental visits, about 24% responded Yes, 47.33%
responded No, 28.67% responded Don’t know. While addressing the question regarding the Awareness in Diabetic individuals about the need to perform better self oral care to maintain a good oral health than Non-Diabetics, 22.1% said Yes, 38.9% said No, while 38.9% said Don’t know. Conclusion: The level of awareness about the possible oral complications due to diabetes and the existence of bidirectional relationship were poor and inadequate among the study participants. Knowledge about the need to maintain a better oral hygiene was also inadequate. A better level of information and communication by the Physician with the Diabetic patient about the association between Diabetes and Periodontal disease could help diabetic patients reduce the occurrence of oralcomplications.
Keywords: Diabetes mellitus, Periodontal disease, diabetic complications, hyperglycemia, Oral disease.
Introduction:
Diabetes mellitus is a metabolic disorder characterised by decreased insulin secretion, action or a combination of both, resulting in hyperglycemia and excretion of glucose in urine. The two types of diabetes are type I and type II. Type II forms about 90% of diabetic cases, which is caused by obesity, sedentary life style, lack of physical activity. Type I Diabetes is a less common type, caused by the autoimmune destruction of beta cells of langerhans. The cardinal features of diabetes includes polyphagia, polydipsia and polyuria.
Oral disease is one of the complication of diabetes mellitus that is less emphasized and discussed with patients by a physician or diabetologist. The hyperglycemia in diabetes mellitus exaggerates the destruction of periodontal tissues, which in turn has negative influence on glycemic
10287 control.1,2 Poorly controlled diabetic individuals are more prone to acute oral infections, dental caries and periodontitis leading to tooth loss.3,4 Various researches have shown adverse bidirectional relationship between diabetes mellitus and periodontal disease.
Periodontitis is an inflammatory disease, mostly of microbial origin, affecting the supporting structures of teeth, resulting in the destruction of periodontal ligament, alveolar bone and eventually loss of tooth. Periodontal disease is the sixth complication of diabetes mellitus.5Some of the periodontal manifestations of poorly controlled diabetes includes extensive alveolar bone loss,6 periodontal destruction,7 poor prognosis to periodontal treatment.8 Periodontitis has been shown to adversely affect glycemic control in diabetic patients, thereby increasing the risk to develop diabetic complications.9Periodontal treatment seem to effectively improve the glycemic control of individual.
Conversely, periodontal disease is an equivalent risk factor in worsening the glycemic control in a diabetic individual, thereby increasing the risk for diabetic complications.10 The gingival sulcus/periodontal pocket forms a niche for the anaerobic gram negative bacteria in the biofilm to reside.11 The ulcerated gingival epithelium provides an access to the bacterial endotoxins, which stimulates the host response, resulting in the activation of proinflammatory cytokines such as Interleukin-1, TNF a, 6, 17, PGE2, MMPs causing periodontal destruction, in addition to which causes systemicdissemination.
Materials and Methods:
The age eligiblility of the participants was between 20 -60 years, with the mean age being 48, ( range 30-63). A total number of 150 participants were included in the study. The study incorporated the use of a self- administered questionnaire in English. For those patients with hindrance of language, the response was marked by the interviewer following explanation of each question and type of response. Questionnaire were distributed to about 150 diabetic patients visiting the Out Patient Department of KarpagaVinayaga Institute of Dental Sciences. The study was commenced after receiving an approval from Institutional EthicalCommittee.
Before the commencement of study, a Pilot study was conducted, where the questionnaire were distributed to about 20 patients, to know the response from the participants. After explaining the purpose of the study, a verbal informed consent was obtained from the patient. Before administration of the questionnaire, a detailed explanation of the study and its purpose was given to the patient. Interested patients participated in the study.Questions were selected from articles published from reputed journals. The pattern of questions in the questionnaire were close-ended (multiple choice questions). The choices in the response of few of the questions were Yes, No, I don’t know. The questions were framed to assess the patient’s awareness about various systemic complications as asequelae to diabetes, also about the impact of diabetes on periodontal /oral health. The highlight issue of the questionnaire was about the awareness of the association between diabetes and oral health. So, some of the questions in the questionnaire are “Have your
physician ever informed about the consequence of diabetes on oral health?”, “What type of diabetes do you have?”, “Have you ever been told by your diabetologist /physician to undergo dental consultation?”, “Are you aware of the complications about the diabetes on general health and various systems of the body?”
Few patients raised their doubts, if their poor oral health was a reflection of their diabetic status, which was clarified by us.
After the participants completion of the questionnaire, they were counselled about the importance of regular and routine visit to diabetologist as part of diabetes care management and the possible correlations between diabetes and oral health and the importance of maintaining a good oral health and the need for frequent dental visits.
Results: Results indicate that the overall patient population had a very poor understanding and little awareness about the association between Diabetes Mellitus and oral complications. Those patients with possible oral health complications could have been prevented with proper communication about impact of Diabetes on oral health had been given by the physician.
Regarding Diabetic patient’s knowledge and awareness about systemic and oral complications associated with Diabetes, in the present study, the percentage of patients who were aware of their increased risk of heart disease is 86.7%, kidney disease 80.7%, eye disease 61.3%, oral infections 37.3%. ( shown in Fig 1)
Fig 1: Diabetic patient’s knowledge and awareness about Systemic and Oral Complications associated with Diabetes
10289 Participant’s knowledge about the type of Diabetes as (shown in Fig.2),about 52.03% had Type II Diabetes, 8.78% had Type I Diabetes, while 39.19% did not know what type of diabetes they had.
Fig 2: Participant’s knowledge about the type of Diabetes
While addressing the question about the percentage of physicians advising the need for frequent dental visits, about 28.67% responded Yes, 47.33% responded No, 28.67% responded Don’t Know. (Fig 3)
Fig 3: Percentage of physicians advising the need for frequent dental visits
While addressing the question regarding the Awareness in Diabetic individuals about the need to perform better self oral care to maintain a good oral health than Non-Diabetics, 22.1% said Yes, 38.9% said No, while 38.9% said Don’t know. (Fig 4)
Fig 4: Awareness in Diabetic individuals about the need to perform better self oral care
Discussion: The data presented in this study reveals an important finding that Diabetics have better knowledge about their increased risk for systemic complications associated with diabetes than they do for oral and dental complications.
Similar findings were reported by several researchers, who assessed the knowledge of Diabetic patients about their increased risk for periodontal disease, their attitude towards oral health and their oral health-related quality of life. Researchers found that 98% of the participants were aware of their increased risk for eye disease, 84% for heart disease, 94% for kidney disease, and 33% for periodontaldisease5.
Individuals with poor glycemic control are three times more susceptible to periodontal disease than well controlled diabetics. The rate of progression of periodontitis is more rapid and severe in diabetics than non-diabetic individuals.There is increasing evidence to suggest bidirectional relationship between diabetes mellitus and periodontaldisease12,13.
Influence of Diabetes on Periodontium:
Research over the recent decades reveals that diabetes is a potent risk factor for the occurrence of periodontal disease. The persistent microbial wound in this site, in the absence of a proper host response, can cause localized tissue destruction or systemic dissemination.
Diabetes with poor glycemic control are at a higher risk to acquire periodontal disease than well controlled counterparts14,15 The micro and macrovascular complications characteristic of hyperglycemia could be a possible mechanism causing periodontal destruction.Macrovascular
10291 complications of Diabetes includes coronary artery, peripheral vascular and cerebrovascular disease. Microvascular complications include neuropathy, retinopathy and nephropathy. Diabetes cause changes in the functions of immune cells namely neutrophils, monocytes and macrophages.
Defects in neutrophil function like adhesion, chemotaxis and phagocytosis increases the bacterial persistence significantly causing periodontal destruction.Hyperresponsive macrophage cause increased production of cytokine and mediators.16Poorly controlled diabetes showed elevated levels of IL-1B GCF levels than well controlled diabetes.17These alterations in the defense system in diabetes caused increased periodontaldestruction.
Impact of inflammatory periodontal disease onDiabetes:
Periodontitis has increased potential of aggravating diabetic complications. Diabetic patients with periodontitis are more prone for a poor glycemic control than diabetic individuals without periodontal disease.18 Periodontal therapy in diabetic patients have proved worthwhile in improving the glycemic control.19,20In diabetic individuals with periodontitis, the inflammatory mediators like TNFα, IL-6, fibrinogen, CRP increased during periodontal disease, worsens insulin resistance, and has a major impact on glycemic status.21,22In periodontal disease, as inflammation is reduced following periodontal therapy, there may be an improved insulin sensitivity, followed by better glycemic /metaboliccontrol.23
Level of awareness among patients about the relationship between Diabetes and oral health:
In the present study, the level of awareness in diabetic patients about the relationship between diabetes and oral health was very less and inadequate. Those patients who responded that they were aware of the link between diabetes and oral health, did after experiencing oral infections during hyperglycemic status. The lack of awareness of patients about the impact of diabetes on oral health might have led to oral health complications like loss of teeth, periodontal abscess.
A detailed interview with the patients also revealed about irregular visits of few individuals and follow up with Diabetologist, which might be possible reason for development of oral health complications. As the potential oral complications were not discussed by the physicians, the diabetic patients were less likely to correlate the impact of diabetes and oral health and vice versa. In the present study, the level of awareness among the diabetic patients about the possible relationship between diabetes and oral health was relatively less 37.3%, compared to their awareness about other systemic complications like heart disease which is about86.7%.
Awareness in diabetic individuals about the need to perform better self oral care to maintain a good oral health than Non-Diabetics:
The participants of the study were made to answer questions addressing about the types and frequency of oral hygiene aids like tooth brushing, dental floss used by them. Knowledge about the need to maintain a good oral hygiene was less. Only 22.1% of the study participants replied that it is important to perform a better oral hygiene than healthy individuals. A lack of awareness was very evident among the participants about the bidirectional relationship between diabetes and oral health. Very less percentage of the diabetic patients were discussed with, informed and
enlightened about the possible relationship between diabetes and oral health and the importance of frequent dental visits by their physicians.
Patients’ Knowledge about the Type of Diabetes: The participants of the survey were asked to answer a question about the type of Diabetes. 8.78 % of participants had Type I Diabetes, while 52.03% of individuals had Type II Diabetes, and 39.19% of the participants did not have any knowledge about the type of diabetes.So, diabetic patients should have a basic knowledge about the type of diabetes and thepotential complications.
Physician’sadvise to consult a dentist for improvement of oral health in diabetic individuals:
A question was included to know if the Physician has ever advised the importance of dental consultation whenever required. 24% of individuals repliedYes, while 47.33%of individuals answered No, and the remaining 28.67% of individuals replied Don’t know. The Physician/Diabetologist need to discuss more with the patients about the potential oral complications as much as the other systemic complications and should insist the importance of frequent dental visits.
Conclusion:The level of awareness about the possible oral complications due to diabetes and the existence of bidirectional relationship were poor and inadequate among the study participants.
Knowledge about the need to maintain a better oral hygiene was also inadequate. A better level of information and communication by the physician with the diabetic patient about the association between diabetes and periodontal disease could help diabetic patients reduce the occurrence of oralcomplications.
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