Influence of Periodontal Disease on Changes of Glycated Hemoglobin Levels in Patients With Type 2 Diabetes Mellitus: A Retrospective Cohort Study

• Autores: Katia L. Costa, Zuila A. Taboza, Gisele B. Angelino, Virginia R. Silveira, Renan Montenegro Jr., Alex N. Haas, Rodrigo Otávio Rego
• Localización: Journal of periodontology, ISSN 0022-3492, Vol. 88, Nº. 1, 2017, págs. 17-25
• Idioma: inglés
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• Dialnet Métricas: 1 Cita
• Resumen

  • Background: Little evidence is available regarding the effects of long-term periodontal infection on diabetes mellitus (DM) control. The aim of this retrospective cohort study is to evaluate influence of periodontal status on changes of glycated hemoglobin (HbA1c) levels of patients with type 2 DM (DMt2).

    Methods: Eighty patients (mean age: 56.0 ± 8.9 years) with DMt2 were included. Patients were non-smokers, aged ≥40 years, and using antidiabetic drugs. Demographics, health history, and HbA1c levels were retrieved from medical charts. Probing depth and clinical attachment loss (AL) were recorded.

    Results: Patients were examined at two time points within a mean interval of 38.6 ± 6.6 months. Increase in HbA1c over time was statistically significant when severe periodontitis was diagnosed at baseline (2.32%, 95% confidence interval [CI]: 1.50% to 3.15%), in patients showing at least one tooth with ≥2 mm of AL progression (2.24%, 95% CI: 1.56% to 2.91%), in males (2.75%, 95% CI: 1.72% to 3.78%), and in those with HbA1c <6.5% at baseline (3.08%, 95% CI: 2.47% to 3.69%). After adjusting for baseline HbA1c, significant changes were still observed for severe periodontitis and progression of AL with increases of 0.85% and 0.9%, respectively. After adjusting for sex and HbA1c, AL progression was also statistically significant, with increases of 0.84%.

    Conclusions: Periodontitis progression was associated with increase in HbA1c in patients with DMt2. Identification of these risk factors suggests that periodontal treatment may improve glycemic control of patients with DMt2 by eliminating periodontal infection.

    Diabetes mellitus (DM) and its complications are some of the most significant and rising chronic health problems in the world, affecting around 415 million people.1 Approximately 90% of these individuals present with type 2 DM (DMt2).1 In Europe 59.8 million adults have DM, including 23.5 undiagnosed cases.1 In the United States, it is estimated that there were 22 million people diagnosed with DM in 2014.2 According to estimates of the latest census, in Brazil >9 million adults were affected, representing 4.5% of the population.3 DM has been associated with periodontitis,4 and the higher the blood glucose levels, the more likely that patients with DM develop periodontitis compared with individuals without DM.5 On the other hand, the inflammatory process associated with periodontitis can interfere with glycemic control in DMt2 as patients with DM showed a decrease of 0.3%6 to 0.4%7 for glycated hemoglobin (HbA1c) levels after periodontal treatment.

    Some possible mechanisms to support this hypothesis have been recently reviewed.8 Inflammatory cytokines, such as interleukin (IL)-1β and IL-6, and the ratio between nuclear factor-kappa B receptor ligand and osteoprotegerin are elevated in patients with DM and periodontitis compared with those only presenting with periodontitis.8 DM-associated hyperglycemia leads to alterations in hemostasis of alveolar bone and formation of advanced glycation end products, which play a proinflammatory and pro-oxidative role in cells.8 Periodontal infection potentiates the vicious cycle in DM, leading to faster periodontal destruction. In contrast, supporting the bidirectional relationship of both diseases, it is suggested that elevated levels of C-reactive protein, IL-6, and tumor necrosis factor-alpha expressed during periodontal disease can negatively interfere with glycemic control.8 A meta-analysis of observational studies, including 47 cross-sectional and eight cohort studies, revealed that DMt2 is a risk factor for periodontal disease, with patients with DMt2 presenting greater clinical attachment loss (AL) compared with patients without DMt2.4 However, only some studies are available that have evaluated the effect of periodontitis on glycemic control in patients with DMt2.9-17 Ide et al.11 evaluated 5,948 Japanese patients with moderate and severe periodontitis as well as healthy periodontal status for 7 years and observed significant association between moderate and severe periodontitis and increased risk for DMt2. When results were adjusted for confounding factors such as triglycerides, a decrease in this association was noted.11 Evaluating Pima Indians with DMt2, in a 2-year follow-up, Taylor et al.12 observed a relationship between severe periodontitis at baseline and increased risk for greater uncontrolled glycemic status. Saremi et al.13 found that, after adjusting for age, sex, DMt2 duration, hypertension, and smoking, risk for cardiorenal mortality increased by 3.2 times in patients with severe periodontitis compared with patients presenting with healthy periodontal status or slight-to-moderate periodontitis. In a 22-year longitudinal study on the effects of periodontitis on onset of nephropathy and end-stage renal disease, Shultis et al.14 observed that periodontitis is a predictor for development of both conditions in patients with DMt2. These cohort studies are relevant owing to longitudinal evaluation of both diseases and can help determine the order in which they occur. Demmer et al.15 followed patients without DM with periodontitis for 5 years and observed an increase in glycemic levels of these patients. The same research group found baseline periodontal disease to be clinically relevant and a predictor of incident DMt2 in a population-based sample representative of adults in the United States.16 Studies have reported incidence and progression of periodontal disease in patients with DMt2 in Brazil;18-20 however, none of them evaluated the effects of chronic periodontal disease progression on DM outcomes. It is deemed important to evaluate patients from a specific geographic area with low socioeconomic and educational status who receive medical treatment from the public health care system, in which the majority of patients with DM and those presenting periodontal disease seek treatment.21 These factors can also be evaluated as risk determinants of the association between these conditions.

    Therefore, the aim of this cohort study is to associate periodontal status at baseline and progression of periodontal disease with changes in HbA1c levels in patients with DMt2.