Maria Periodontology Alexandra Martu, T. Stefanache, Liliana Pasarin, Liliana Foia, Silvia Martu EVALUATION OF GLYCEMIA AT THE LEVEL OF SULCULAR AND CAPILLARY BLOOD IN DIABETIC PATIENTS WITH PERIODONTAL DISEASES 1. VIth year student, Gr.T.Popa UMPh of Iasi 2. Univ. assist., PhD, Gr.T.Popa UMPh of Iasi, Periodontology 3. Professor, Gr.T.Popa UMPh of Iasi, Biochemistry 4. Professor, Gr.T.Popa UMPh of Iasi, Periodontology Contact person: Martu Silvia: parodontologie1@yahoo.com Maria Alexandra MARTU 1, T. STEFANACHE 1, Liliana PASARIN 2, Liliana FOIA 3, Silvia MARTU 4 Abstract Scope of the study: A reliable, rapid and non-invasive evaluation of the patients suffering from diabetes mellitus through investigation of glycemia from the sulcular (crevicular) gingival blood. Materials and method: Laboratory investigations were made for evaluating the glycemia from the capillary (CBGL) and crevicular (SBGL) blood in 60 patients with periodontitis (30 suffering from diabetes, 30 non-diabetics), the obtained data being analyzed statistically. Results: The mean values of glycemia (at both MSBG-sulcular and MCBG-capillary level), expressed in mg/dl, were of 168.60 and, respectively, 190.57. The MCBG level was of 269.73 for the group with diabetes and of 111.40 for the non-diabetic ones, respectively, whereas the MSBG level was of 240.217 for the first group and of 97.03 for the second one. An important correlation could be also observed between the levels of these values and the degree of periodontal affection. Conclusions: Testing of sulcular blood may represent an adequate, rapid and reliable method for the identification of patients affected with diabetes, permitting to recommend a new screening protocol. Keywords: periodontitis, diabetes mellitus, capillary glycemia, sulcular glycemia INTRODUCTION Diabetes mellitus is the most frequently occurring metabolic disease caused by disorders of the lipidic, proteic and carbohydratic metabolism. An increased glycemia affects the eyes, nerves, skin, blood vessels and other organs [1]. In spite of the extreme impact of this malady, almost 50% of the patients are not aware of the severe problem they suffer [2]. Diabetes may be also accompanied by certain manifestations in the orai cavity, such as xerostomia, viral and fungic infections, delayed healing rate, increased frequency of caries, sensation of mucous membranes burning, abscesses, etc. [3]. Periodontal maladies represent the sixth category of complications caused by diabetes, transforming it into a major risk factor, influencing the incidence and severity of the periodontal affections [4]. The prevalence of diabetes in patients suffering from periodontitis is higher than in the periodontally healthy ones. Consequently, a higher number of patients with periodontitis may suffer from a non-diagnosed diabetes [5]. The level of glycemia in blood may be measured either venously or capillarly. Other studies consider the level of tear glycemia in both diabetic and non-diabetic patients, indicating the high level of tear glycemia in diabetics [6]. Nowadays, several methods are in use for the determination of glycemia. Having in view that 50% of the diabetics remain undiagnosed, testing of the sulcular blood may become a suitable method for the identification of diabetic patients during routine stomatological controls, if a correlation with the capillary blood exists. The glucometer is the most popular and non-invasive device utilized for this end. SCOPE OF THE STUDY The scope of the present study was to evaluate the correlation between the glycemia of the capillary blood (CBGLs) and the level of glycemia from the sulcular blood (SBGLs), on using blood from gingival tissues collected during routine 286 volume 3 issue 4 October / December 2013 pp. 286-290
EVALUATION OF GLYCEMIA AT THE LEVEL OF SULCULAR AND CAPILLARY BLOOD IN DIABETIC PATIENTS WITH PERIODONTAL DISEASES periodontal examinations, for establishing whether the sample of sulcular blood may be employed as a means of non-invasive diagnosis in the determination of glycemia. MATERIALS AND METHOD The study included 30 non-diabetic and 30 diabetic patients suffering from moderate up to severe periodontitis, randomly selected from the initial group of patients affected with diabetes and subjected to some routine clinical periodontal examinations. Neither sex nor age have been employed as exclusion criteria. The SBGLs and CBGLs values have been measured with a glucometer. The blood was collected with a 1.6-1.8 mm in diameter tube, used to transport the sample from the gingival sulcus of the anterior teeth, following probing of the periodontal pocket, on the test strip of the self-monitorization device of glycemia. The capillary blood used as control sample was taken over from the finger. After the periodontal probing of sextant 2 (favourized by a suitable access and isolation), included in the study were the patients with periodontal pockets between 5-7 mm or larger. Prior to probing, all subjects were subjected to rinsings with chlorhexidine (0.12%), for an as much as possible reduction of the microbial flora occurring in the region. Probing was realized with an UNC 15 probe, after complete isolation. The blood leaked from the gingival tissues was taken over with a 1.6-1.8 mm in diameter micro-tube and transported on specific test bands, after which the level of glycemia was measured on a Prestige IQ Blood Glucose Monitor (Home Diagnostics, Inc., Ft. Lauderdale, FL, USA). Prior to taking over of the capillary blood samples, the patients were asked to wash the index of their right hand with water and soap. The samples were obtained with an auto lantent, a device of skin puncture, after which the drop of blood was transported to the glucometer employed for analysis. The data were registered and analyzed with the Pearson correlation, together with t-tests, on using the SPSS statistical program, version 11.5 (SPSS, Inc., Chicago, IL, USA). RESULTS The study included 60 patients (30 men and 30 women) with an average age of 42.98 years. The demographic results are presented in Table 1. Table 1. Characteristics of the experimental group Age (years) 46±_ 8 Sex Women 30 (50%) Smoker Yes 39 (42%) Index of bodily weight (kg/m 2 ) Family history of metabolic glucidic diseases Periodontal diagnosis Nr of samples collected in the beginning of the study 25.3 ± 3.7 Yes 25 (26%) Chronic periodontitis 70 (75%) 27± 3 Nr of repeated samples 2 ± 2 Men 30 (50%) No 55 (58%) No 69 (74%) The reported values are ±SD (standard deviation). Aggressive periodontitis 24 (25%) The mean values of capillary (MCBG) and sulcular glycemia (MSBG) registered from all samples were of 190.57 and 168.6, respectively. The MCBG level was of 269.73 in the test group and of 111.4 in the control one (Table 2), whereas the MSBG level was of 240.27 in the test group and of 97.03, respectively, in the control one (Table 3). 21 (70%) of the diabetic patients and 5 (17%) of the non-diabetics had had diabetes in their family history. A family history of exposure between the 2 groups appears as significantly different. Tables 2 and 3 reveal significant differences between the MCBD and MSBG values in the test and, respectively, control group (p=0.0001). International Journal of Medical Dentistry 287
Maria Alexandra Martu, T. Stefanache, Liliana Pasarin, Liliana Foia, Silvia Martu Table 2. Mean values of capillary glycemia (MCBG) Test 30 269.73 139 477 84.91 T=9.39 Control 30 111.40 64 242 36.35 P=0.0001 Table 3. Mean values of sulcular glycemia (MSBG) Test 30 240.27 129 418 74.95 T=9.49 Control 30 97.03 58 242 31.67 P=0.0001 Table 4.Mean CBGLs values as a function of sex Men 30 183.53 64 384 103.21 T=0.53 Women 30 197.60 91 477 103.65 P=0.60 Table 5. Mean SBGL values as a function of sex Men 30 163.23 58 359 93.28 T=0.45 Women 30 174.07 91 418 92.04 P=0.65 Table 6. Mean CBGLs values as a function of the severity of the periodontal disease Group Nr Mean value SD Test Moderate periodontitis 24 161.75 92.37 T=1.81 Severe periodontitis 36 209.78 106.09 P=0.076 Table 7. Mean SBGLs values as a function of the severity of the periodontal disease Group Nr Mean value SD Test Moderate perodontitis 24 142.54 92.37 T=1.83 Severe periodontitis 36 186.06 95.90 P=0.072 Table 8. Correlaton between capillary and sulcular glycemia Group Nr CBGL SBGL Test Test 30 1 0.993 Odds=0.01 Control 30 1 0.990 Odds=0.01 The MCBG and MSCB levels as a function of sex (Tables 4 and 5) and of the various degrees of periodontitis severity (Tables 6 and 7) are not statistically significant. Nevertheless, a higher average value of the glycemia level was observed in patients affected with severe periodontal diseases. Whichever the classification at subgroup level, a higher correlation was observed between the MSBG and MCBG levels among all participants to the study (r =0.997, p=0.0001) (Table 8). More than that, a higher correlation was also noticed between the MSBG and MCBG levels in patients with different degrees of periodontal disease severity. 288 volume 3 issue 4 October / December 2013 pp. 286-290
EVALUATION OF GLYCEMIA AT THE LEVEL OF SULCULAR AND CAPILLARY BLOOD IN DIABETIC PATIENTS WITH PERIODONTAL DISEASES DISCUSSION The study was developed on 60 patients (30 men and 30 women), with a mean age of 42.98 years. The mean values of capillary glycemia (MCBG) and of sulcular glycemia (MSBG) registered in all samples were of 190.57 and 168.6, respectively. The MCBG level was of 269.73 in the test group and of 111.4 in the control one, whereas the MSBG level was of 240.27 in the test group and of 97.03, respectively, in the control one. 21 (70%) of the diabetic patients and 6 (17%) of the non-diabetics had had diabetes in their family history. Diabetes mellitus is a malady that may cause a large range of complications, such as retinopathy, nephropathy, neuropathy, vascular diseases (micro and macro angiopathies), delayed healing processes and periodontal diseases [3]. The recommendation made to all healthy persons older than 45 years, not exposed to the risk factors of diabetes, is to be evaluated each 3 years. The persons showing risk factors for diabetes mellitus should be checked earlier and at much shorter intervals. Precise, reliable and non-invasive means for glycemia investigation were quite easily established. Sulcular bleeding is a normal consequence of the periodontal examination, caused by tissue inflammation, produced in both diabetic and non-diabetic patients. The main objective of the present study was to achieve a reliable, non-invasive and rapid evaluation of the diabetic status of patients, through SBGL estimation during the periodontal examination. Several studies evaluated the correlation between the glycemia recorded at sulcular and peripheric blood level [7-11]. Parker [8] reported a major correlation between sulcular and capillary glycemia (r=0.8), which agrees with the results of our investigation (r=0.99). Beiker [9] also reported a significant correspondence, using a glucometer for comparing capillary and sulcular glycemia (r=0.98), which also agrees with the conclusions of the present study. In the year 2001, Almas declared that the severity of the periodontal disease is directly associated with glycemia [12]. The subjects considered in his study suffered from type II diabetes, another aspect confirmed by our investigation, in which 20 patients with severe periodontitis showed increased glycemia values. Patino-Martin analyzed the rate of periodontitis prevalence among non-diagnosed diabetic patients, healthy patients or patients with controlled-diabetes, [13] concluding that the prevalence of this disease is much higher in patients with uncontrolled diabetes, comparatively with the healthy ones. Similar results have been also recorded in the present study. In 2004, Lu evaluated the effect of periodontitis severity among diabetic patients and showed that diabetes as such represents a primary factor among those influencing the severity of the periodontal maladies [14]. Age represents another factor influencing the installation, in old patients, of much more severe periodontal diseases which also agrees with the observations of our study. The dentist might use this (sulcular) blood for glycemia tests, thus avoiding the finger prick test for obtaining blood samples subsequently sent to a clinician, in view of diabetes ascertainment. CONCLUSIONS The conclusions of the present study point to a significant correlation between SBGLs and CBGLs, in both diabetic and healthy patients, whichever their sex. The presence of diabetes mellitus in the family history, as well as a higher severity of the periodontal disease were noticed in patients suffering from diabetes. Once knowing that 50% of the diabetics remain non-diagnosed, testing of sulcular blood, during routine stomatological controls, may appear as an adequate method for the identification of potentially diabetic patients, in correlation with the capillary blood, and their further presentation to a specialized clinician. References 1. Garcia RI., Henshaw MM., Krall EA. Relationship between periodontal disease and systemic health. Periodontology 2000 2001; 25:21-36. International Journal of Medical Dentistry 289
Maria Alexandra Martu, T. Stefanache, Liliana Pasarin, Liliana Foia, Silvia Martu 2. Ardakani MRT, Moeintaghavi A, Haerian A, Ardakani MA, Hashemzadeh M. Correlation between levels of sulcular and capillary blood glucose. J Contemp Dent Pract 2009; 10(2):10-7. 3. Dennison DK, Gottsegen R, Rose LF. Diabetes and periodontal disease. J.Periodontol. 1996; 67:166-76. 4. Loe H. Periodontal disease: The sixth complication of diabetes mellitus. Diabetes Care 1993; 16:329-34. 5. Neuman M, Takei, Kelokuld N, Carranza F. Molecular biology of host-microbe interaction in periodontal diseases in Clinical periodontology 10 th edition: WB Saunders Co; 2006: 313-315. 6. Das BN, Senguapta S, Das BK, Goswami NR. Tear glucose estimation: an alternative to blood glucose estimation. J Indian Med Assoc 1995; 93:127-8. 7. Prabhu S, Seshan H, Deshpande A. Reliability of using gingival crevicular blood in the diagnosis of diabetes. JIADS 2010; 1(3):16-18. 8. Partker RC, Rapley JW, Isley W, Spencer P, Killoy WJ. Gingival crevicular blood for assessment of blood glucose in diabetic patients. J Periodontol 1993; 64:666-72 9. Beikler T, Kaczek A, Petersilka G, Flemming TF. In- Dental-Office screening for diabetes mellitus using gingival crevicular blood. J Clin Periodontol 2002; 29:216-8. 10. Muller HP, Behbehani E. Methods for measuring agreement: glucose levels in gingival crevice blood. Clin Oral Invest 2005; 9:65-9. 11. Yamaguchi M, Kawabata Y, Kambe S, Wardell K, Nystrom FH, Naitoh K, Yoshida H. Non-invasive monitoring of gingival crevicular fluid for estimation of blood glucose level. Med Biol Eng Comput 2004; 42:322-7. 12. Almas K, Al-Qahtani M, Al-Yami M, Khan N. The relationship between periodontal disease and blood glucose level among type II diabetes patients. J Contemp Dent Pract 2001; 21:18-25. 13. Patino-Martin N, Loyota-Rodriguez JP, Valadez- Castillo FJ, Hernandez-Sierra JF, Pozos-Guillen Ade J. Effect of metabolic control in type I diabetes patients and its association with periodontal disease. Rev Invest Clin 2002; 54:218-25. 14. Lu HK, Yang PC. Cross-sectional analysis of different variables of patients with non-insulin diabetes and their periodontal status. Int J Periodontics Restorative Dent 2004; 27:71-9. 290 volume 3 issue 4 October / December 2013 pp. 286-290