The Effect Of Non-surgical Therapy On Type 2 Diabetes Mellitus Patients With Chronic Priodontitis

Diabetes mellitus is one of the most common metabolic disorders characterized by hyperglycemia. Diabetes mainly divided into two types:type 1 diabetes mellitus usually called insulin-dependent-diabetes mellitus (IDDM),is caused by cellular mediated autoimmune destruction of pancreaticβ-cell, and resulting in an absolute lack of insulin;Type 2 diabetes mellitus usually called non-insulin-dependent-diabetes mellitus (NIDDM), which is the main type of diabetes and account for nearly 85 percent to 95 percent of the diabetes, is caused by progressive damage of insulin secretion under insulin resistance. However, the blood glucose level of 40 percent of patients with type 2 diabetes still cannot be effectively controlled, even under good control of food and medication, indicating that there may exists other risk factors affecting glucose metabolism.Periodontitis is a chronic infectious disease caused by plaque microbes, which is the main cause of adult tooth lost.In our country, the incidence of periodontitis is approximate 80 percent to 90 percent in adults.Recent studies found that periodontitis not only affect periodontal tissue, but also is an important potential risk factor for certain systemic disease or abnormality (such as cardiovascular disease, diabetes, preterm delivery and low birth weight and respiratory infections, etc.). Periodontitis and diabetes are both chronic inflammatory diseases associated with multiple genes and risk factors.The onset of both diseases share similar risk factors.A lot of studies suggests that exists two-way relationships between periodontal disease and glucose metabolism level.Currently, the influence of diabetes to periodontal disease has been widely recognized, but the influence of periodontitis on diabetes has not been supported with sufficient evidence.The objective of this study using open, randomized, longitudinal design was to explore the effect of periodontal non-surgical therapy on periodontal local inflammation, metabolic level and systematic inflammation in type 2 diabetes patients with chronic periodontitis.Objectives:1. To establish periodontitis clinical database information, questionnaire and biological sample library of China's Han with type 2 diabetes.2. To observe the effect of periodontal non-surgical treatment on periodontal tissue inflammatory, glucose metabolism level, lipid metabolism level and serum inflammatory markers in patients with type 2 diabetes.Methods:1.Subjects collectionFrom March of 2008 to December of 2009, total of 147 type 2 diabetes patients with chronic periodontitis were collected from five diabetes centers in Guangzhou. Inclusion criteria:diagnosed as type 2 diabetes over one year, free of serious complications, and chronic periodontitis. Exclusion criteria:systemic diseases other than type 2 diabetes such as coronary heart disease; HbA1c》10%; active infections other than periodontitis; pregnancy, breast-feeding or plan to become pregnant during treatment; acute periodontal abscess; refused to participate in this study; intake of antibiotics in the previous 4 weeks; periodontal treatment within the last six months. The written informed consent was obtained from all the included subjects, then, divided into treatment and control groups by randomly in a 2:1 ratio.2. Periodontal treatment interventionAt baseline, the treatment group received non-surgical periodontal treatment; Control group did not receive any periodontal treatment, other than oral hygiene education. At 3 months,6 months and 12 months returned visit, the treatment group received periodontal intervention, including scaling and root planning when necessary, and the control group remained the same treatment of oral hygiene education as at baseline.3. Clinical data collectionAt baseline and every return visit, the periodontal index (including periodontal pocket depth PD, plaque index PLI, bleeding index BOP, AL attachment loss), sugar metabolism (fasting plasma glucose FPG and glycated hemoglobin HbA1c), lipid metabolism (total cholesterol, TG, high density lipoprotein HDL, low density lipoprotein LDL, triglycerides TC), inflammatory cytokines (tumor necrosis factor TNF-αand high sensitivity C-reactive protein CRP), were all examined and recorded.4. Statistical analysisAll the data were analyzed using SPSS 13.0 statistical software, Bilateral level at P<0.05 was selected. With the balance between two groups at baseline, the differences of the test parameters between different visit points before and after non-surgical periodontal treatment were analyzed with ANOVA, when the test of sphericity was not been satisfied, Greenhouse-Gerisser method was used. Inter-group comparison was analyzed using two-sample t test. When the data do not meet the normal distribution, they were transformed by natural logarithm function to normal distribution and then analyzed. Missing data were treated with the LOCF (Last observation forward) method.Results1. In this study, the total of 147 patients were included,12 lost,135 people entered the last stage of follow-up observations, including 90 in treatment group and 45 in control group, and total of 100 subjects finished follow-up to 12 months after treatment.2. There was no significant difference for basic information between groups. The age (t=-1.978, P=0.050), illness duration (t=-1.633, P=0.107), BMI (t=0.434, P =0.665), number of missing teeth (t=-0.498, P=0.619), initial HbA1c (t=0.324, P =0.746), gender (χ2=2.51, P=0.113), smoking (χ2= 0.333, P=0.846), treatment (χ2=0.514, P=0.773), drinking wine (χ2=1.80, P=0.180), pressure (χ2=1.35, P =0.245), regular exercise(χ2=0.088, P=0.767).3. The results showed that the average PD of the treatment group decreased with over time statistical significance (F=64.013, P=0.000), and to a minimum in the 6 months. PD of control group also decreased over time, but without significance (F= 2.390, P=0.099). The difference between two groups showed statistical significant. This suggest that non-surgical periodontal treatment can significantly improve periodontal inflammatory in type 2 diabetes mellitus with chronic periodontitis.The average BOP (FBOP=95.810,P=0.000) and average PLI (FPLI=47.638, P=0.000) of the treatment decreased with over time statistical significance. The average BOP (FBOP=4.796,P=0.009) and average PLI (FPLI=6.290,P=0.002) of the control also decreased with over time statistical significance, and also there was statistical significance between two groups, the decreae in the treatment group was significantly higher than in control group. This suggest that non-surgical periodontal treatment can effective control periodontal inflammatory, and regular and effective oral hygiene instuction also promote periodontal inflammatory. 4. HbA1c of treatment group (F=7.775,P=0.000) decreased with significant difference over time, HbA1c of control group (F=2.127,P=0.097) decreased with no significant difference, and there was no significant difference between the two groups (F=0.235, P=0.629). This suggest that non-surgical periodontal treatment can improve HbA1c in type 2 diabetes mellitus with chronic periodontitis, but the evidence is not sufficient.5. The level of lipid metabolism in the treatment group (TG, HDL, LDL, TC) decreased over time(FTG=1.787, P=0.156, FHDL=5.779, P=0.000, FLDL=3.731, P=0.009, FTC=3.279, P=0.015), the control group also decreased (FTG=3.301, P =0.026, FHDL=3.180,P=0.031, FLDL=2.844, P=0.038, FTC=1.937, P=0.106), but differences between the two groups does not reach significance. This suggests that non-surgical periodontal treatment not yet improve the level of lipid metabolism in type 2 diabetes mellitus with chronic periodontitis.6. Serum inflammatory factors of treatment group(CRP and TNF-α) with a downward trend over time (FCRP=3.242, P=0.033, FTNF-α=1.148, P=0.306), there was no significant difference in the control group (FCRP=0.681, P=0.525, FTNF-α= 1.733, P=0.195), but differences between the two groups does not reach significance. This suggests that non-surgical periodontal treatment can improve the level of CRP in some extent, and it not yet can improve the level of TNF-α.Conclusion1. Through non-surgical periodontal treatment, in type 2 diabetes patients with chronic periodontitis, periodontal inflammation can be effectively controlled, and regular and effective oral hygiene instuction also promote periodontal inflammatory;2. There was no sufficient evident to support that non-surgical periodontal treatment can improve the levels of HbA1c and CRP in diabetic patients.3. It is still unclear whether non-surgical periodontal therapy in type 2 diabetes with chronic periodontitis significantly improved serum lipid metabolism and the level of inflammatory cytokines TNF.