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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 249-253

Evaluation of periodontal status amongst the diabetic patients visiting private dental clinic in ahmedabad using CPITN

1 Sankalchand Patel University, Visnagar, Gujarat, India
2 Department of Periodontics, NP Dental College and Hospital, Visnagar, Gujarat, India
3 Department of Prosthodontics, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India
4 Department of Periodontics, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India
5 Department of Public Health Dentistry, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India
6 Department of Oral Pathology, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India

Date of Submission15-Sep-2022
Date of Acceptance29-Jul-2022
Date of Web Publication15-Sep-2022

Correspondence Address:
Dr. Eshita Dasharathbhai Patel
Department of Periodontics, AMC Dental College, Ahmedabad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_141_21

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Introduction: To determine the periodontal status and treatment needs using CPITN in a group of adult diabetic patients attending OPD in a private dental clinic in Ahmedabad. Materials and Methods: One hundred and two diabetic patients were screened by a single examiner according to the WHO criteria using a mouth mirror and CPITN probe. The patients were selected from the routine OPD after obtaining verbal consent for the same, and about 76 patients were included in the study, which was carried out for 9 months. Results: Results showed that the highest number of patients had code 3. The majority of sextants had code 2 and 3. Amongst all, 42 patients had a TN score of 2 and 33 had TN score of 3. 56–65 age groups had the worst periodontal status among all groups and required the highest periodontal treatment. Conclusion: The periodontal health of our diabetic patients reinforces the need to establish a comprehensive oral health promotion programme for diabetic patients with a multidisciplinary approach.

Keywords: CPITN index, diabetes mellitus, periodontal disease

How to cite this article:
Patel ED, Parikh HA, Shah R, Mandaliya D, Vishwkarama S, Nayak S. Evaluation of periodontal status amongst the diabetic patients visiting private dental clinic in ahmedabad using CPITN. Adv Hum Biol 2022;12:249-53

How to cite this URL:
Patel ED, Parikh HA, Shah R, Mandaliya D, Vishwkarama S, Nayak S. Evaluation of periodontal status amongst the diabetic patients visiting private dental clinic in ahmedabad using CPITN. Adv Hum Biol [serial online] 2022 [cited 2023 Feb 7];12:249-53. Available from: https://www.aihbonline.com/text.asp?2022/12/3/249/356105

  Introduction Top

Diabetes mellitus is a chronic metabolic disorder of carbohydrate metabolism characterised by glycosuria and hyperglycaemia. It currently affects more than 100 million people worldwide. This number is expected to shoot up by the year 2025.[1] In India, there are more than 15 million people with diabetes, and it stands fifth as a killer disease.[2] Diabetes can be classified into two major categories: Type I or insulin-dependent diabetes and Type II or non-insulin-dependent diabetes.

A two-way relationship exists between diabetes mellitus and periodontal disease. Diabetes mellitus is a systemic disease with several complications affecting both the quality and length of life. Diabetes mellitus develops in case of a disturbance of glucose homeostasis in the organism, in the presence of insulin deficiency, resulting in the metabolism of carbohydrates, proteins and fats. This is a severe endocrine pathology attributed to the group of chronic non-infectious metabolic diseases. Systemic manifestations of the disease include arteriosclerosis, microangiopathy, glomerulopathy and atherosclerotic heart disease.[3]

Periodontitis may impair metabolic control, and adequate treatment of periodontitis can improve glycaemic control (Stewart et al. 2001).[4] Loe has recently declared periodontal disease as the 'sixth' complication of diabetes mellitus. Rees, in a review paper, concluded that there is a direct relationship between diabetes mellitus and periodontal disease.[5]

A variety of periodontal changes have been described in diabetic patients, such as a tendency towards abscess formation, diabetic periodontoclasia, enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferation and loosened teeth. The relationship between diabetes mellitus and periodontal disease has been extensively studied. The oral hygiene status affects the development of the inflammatory pathology of periodontal tissues.[6]

The present study was conducted to examine adult diabetic patients and assess the possible relationship between diabetes mellitus and periodontal disease using CPITN index with the aim and objective of:

Aim and objective

To determine the periodontal status and treatment needs using CPITN in adult diabetic patients visiting a private dental clinic in Ahmedabad.

  Materials and Methods Top

The study on the oral health status and treatment requirements of adult diabetics was conducted in a private dental clinic in Ahmedabad. The survey was conducted during 9 months period from 1st October 2020 to 30th June 2021. Ethical clearance was obtained from the Ethics Committee of Ahmedabad Dental College and Hospital (ADCH/IEC/2020/29). The study group was selected from routine daily patients who were attending the OPD and who had volunteered to participate in the study. Patients explained the entire study verbally, and then, written consent was obtained for the same. The subjects consisted of patients with diabetes for >1 year and <5 years. Detailed medical and dental history was taken with verbal consent for the study.

All the patients were examined by a single examiner on a straight chair under artificial light using a plane mouth mirror and the Community Periodontal Index of Treatment Needs (CPITN; WHO 1984)[7] CPITN probe. A 0.5 mm ball-ended probe with colour markers at 3.5 and 5.5 mm is used to measure the CPITN. The WHO recommends that the pressure applied with the probe should not exceed 20 g. The instruments were sterilised chemically, and scoring was done according to the WHO criteria. Patients with a fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or higher or A 2-h plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test, were included in the study.[8] Patients with Type II diabetes since >1 year and <5 years and having more than 15 permanent teeth in the dentition were included in the study. Those with a history of any other systemic illness other than diabetes mellitus or having ketosis/diabetic ketoacidosis in the 2 months preceding the study, patients who have taken antibiotics in the last 6 months or are on long-term medications such as cortisone, hydantoin and non-steroidal anti-inflammatory immunosuppressive drugs were excluded from the study. Even pregnant patients and those with <15 teeth in the oral cavity were excluded from the study.

Out of 102 diabetic patients selected, 76 patients (39 males and 37 females) were accepted for the study and the remaining were excluded from the study.

Individual CPITN score was made for each sextant containing at least two functional teeth, excluding third molars, according to the highest CPITN score. For each of the 6 sextants (17–14, 13–23, 24–27, 37–34, 33–43 and 44–47), the CPITN measures the following conditions: no treatment needs (score 0), bleeding gingiva on gentle probing (score 1), presence of supra- or subgingival calculus or other plaque retentive factor (score 2), 4 or 5 deep periodontal pockets (score 3) and 6 mm or deeper periodontal pockets (score 4). For each, six sites are examined: mesial, midline and distal on both vestibular and lingual/palatal surfaces. Among adults aged 20 years or more, WHO suggests examining only 10 teeth: 17, 16, 11, 26 and 27 in the maxilla, and 47, 46, 31, 36 and 37 in the mandible. Molars are examined in pairs, and the highest score is recorded for each sextant. A sextant is examined if at least 2 teeth are present. If none of the index teeth is present in the sextant, all the teeth remaining in the sextant are examined.

There are two ways of presenting the CPITN. The most common is to indicate the percentage of subjects according to each category of the CPTN. The second, less often used, presents the mean number of sextants requiring treatment by subjects. From a treatment perspective, the second method appears more efficient as in practice, periodontal treatment is done by sextant and not individually for each tooth. Lewis et al. 1994 recommended turning the mean number of sextants in each category into a percentage of affected sextants to compare it with the percentage of subjects affected.[9] Data were collected SPSS version 18 (SPSS Inc. Released 2009. PASW Statistics for Windows, Chicago). The data was analysed using the Chi-square test P < 0.05 was considered significant.

  Results Top

Results showed that periodontal status was worse in diabetic patients. [Table 1] and [Figure 1] show that the highest number of patients had code 3 and 4. Age groups 46–55 and 55–65 are highly affected groups.
Table 1: Subjects-wise distributions of periodontal status in different age groups

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Figure 1: Subjects-wise distributions of periodontal status in different age groups.

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[Table 2] shows the mean value of 3.04 at a standard deviation of 3.62 for total number of participants. Age group 55–65 shows the highest value.
Table 2: Distributions of periodontal status in different age groups (subjects wise)

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[Table 3] shows sextant wise distributions of periodontal status in different age groups, wherein 197 sexants (43.2%) had code 2, 165 (36.18%) had code 3 and 88 (19.29%) had code 4. The most affected age groups were again 46–55 and 56–65. The results of [Table 2] and [Table 3] are clearly in [Figure 2].
Table 3: Sextant-wise distributions of periodontal status in different age groups

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Figure 2: Comparison between percentage of subjects and percentage of sextants according to CPITN.

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The majority of sexants had code 2 and 3. [Table 4] shows that the mean number of sexants with code 2 was 2.39 and with code 3 was 2.09, respectively.
Table 4: Mean number of sextant affected

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Amongst all the participants, 42 patients had TN score of 2 and 33 had TN score 3, as shown in [Table 5]. Hence, most of the subjects required scaling root planning, followed by others who required surgery also.
Table 5: Subject-wise periodontal treatments in different age groups

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[Table 6] shows the need for periodontal treatment in different age groups showed a mean value of 3.8 at a standard deviation 4.54.
Table 6: Needs for periodontal treatment in different age groups (subjects wise)

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[Figure 3] shows the overall results for treatment needs in different age groups. 56–65 age group has the highest TN3 score and the 46–55 age group has the highest TN2 score among all age groups. Hence, both the age groups need periodontal treatment, including scaling root planning to complex surgical procedures.
Figure 3: Needs for periodontal treatment in different age groups.

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  Discussion Top

Three broad strategies for the prevention of periodontal disease have been advocated (i) a population strategy, (ii) a secondary prevention strategy and (iii) identification of high-risk groups for periodontitis (Sheiham 1991).[10] If the goal is to identify high-risk groups, early detection of active disease and identification of subjects and groups who are more likely to develop destructive periodontal diseases in the future are important elements of the dental care system. This applies particularity to high-risk groups, such as adult diabetics. Diabetes mellitus is one of the major chronic health problem.[2] Data on prevalence and incidence of disease can help in evaluating the significance of a disease and its consequences. The IDF Diabetes Atlas Tenth edition 2021 provides the latest figures, information and projections on diabetes worldwide, stating that approximately 537 million adults (20–79 years) are living with diabetes.[11]

The constant need of diabetics for regular intake of nutrition to maintain good blood glucose control facilitates the growth of dental plaque, and thus, the development of oral plaque derived from the presence of periodontal disease observed in the present study emphasises the necessity of oral hygiene counselling in diabetics. A study in Bangladesh showed that in addition to diabetes-related clinical determinants, self-care practices and oral hygiene practices must be taken into consideration for the prevention and control of periodontal disease in patients with diabetes.[12] In diabetic patients, quality of life and lifestyle factors which systemically alter microvascular and immunological functions seem to predict periodontitis.[13]

The main objective of the present study was to assess the periodontal treatment needs of a group of patients attending a dental hospital. The individuals of different ages and sex coming from various parts of the city visited the hospital. With the help of the data collected, an attempt was made to throw some light on the variations and changes in periodontal treatment needs in the sample that could be applied to society in a broad sense. This will further help in the planning and implementation of effective oral health programs and services.

The CPITN recording has been applied in several studies worldwide.[14],[15] as it has been widely recommended (Petersen and Ogawa 2005)[16] to increase international uniformity. The CPITN is designed for rapid and practical assessment of various periodontal treatment needs in population surveys.[17] The advantages of CPITN include simplicity, speed and reproducibility.[16] The CPITN system developed and evaluated by the WHO-FDI joint working group committee proved to be a very simple, quick and efficient method of assessing treatment needs with high reproducibility. The strong correlation with diabetes probable reflected the cumulative effect of the disease. The present study helps to increase public awareness, which in turn will help to reduce the prevalence and severity.

Here from 76 patients, 1.32% required TN1, 55.26% required TN2, 43. 42% required TN3. 56–65 age group had a highest code 2. 46–55 age group had a highest code 3. Of all the patients, maximum patients were under code 3 and 4. In the present study, all subjects in all age groups needed oral hygiene instructions, and almost all of them required calculus removal. This reflects the poor level of oral hygiene and indicates the magnitude of the efforts required to overcome the situation.

By this study, a group of patients more susceptible to the development of destructive forms of periodontal disease could be more precisely identified. In a similar study, the prevalence of periodontitis was found to be higher than gingivitis among patients with diabetes mellitus Type 2.[18],[19] The severity of periodontitis is found to be greater in poorly or uncontrolled diabetic patients;[20] and hence, the influence of general health on oral health and diseases can be emphasised, thereby helping to avoid any undesirable events. A similar study in Rawalpindi concluded that the dental health status of Type II diabetics with longer disease duration and poor glycaemic control was compromised. Statistically, a significant association was reported between diabetes duration and status of oral health.[21] In contrast to other studies, Alkanderi and Jospeh concluded that diabetic patients' level of knowledge about the effect of diabetes mellitus on their general and dental health was found to be good.[22] Another survey highlighted that frequent tooth brushing was associated with reduced risks of incident hypertension and Type 2 diabetes mellitus.[23]

  Conclusion Top

Oral hygiene instruction was required for all the diabetics, 55.26% of them required scaling, and 43.42% required complex treatment. Lack of awareness of the periodontal disease among diabetic patients and insufficient accessibility to periodontal treatment may be the reason for the poor periodontal health of our patients. Thus, effective health education could do much to reduce the incidence of clinically expressed oral disease. Overall, people with diabetes have limited oral health knowledge and poor oral health behaviours. It is therefore essential to educate patients about their increased risk for oral health problems, motivate them for good oral health behaviours and facilitate access to dental care.[24],[25]

More co-operative work is needed between those involved in general health and dental care of diabetics, with emphasis on increasing the understanding of the relationship between diabetes and oral health, particularly periodontal disease. Thus, a patient-centred collaboration requires paradigm shifts in awareness, attitude, education and medical and dental practice for all health-care professionals[26] and to achieve optimal diabetic care, and periodontal care should be incorporated into the management plan of diabetic patients.[27]

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Puranik MP, Hiremath SS. Oral health status and treatment needs among adult diabetic and nondiabetic patients in Banglore city – A comparative. J Indian Assoc Public Health Dent 2006;8:31-7.  Back to cited text no. 2
Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: A two-way relationship. Ann Periodontol 1998;3:51-61.  Back to cited text no. 3
Stewart JE, Wager KA, Friedlander AH, Zadeh HH. The effect of periodontal treatment on glycemic control in patients with type 2 diabetes mellitus. J Clin Periodontol 2001;28:306-10.  Back to cited text no. 4
Löe H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.  Back to cited text no. 5
Sadzeviciene R, Paipaliene P, Zekonis G, Zilinskas J. The influence of microvascular complications caused by diabetes mellitus on the inflammatory pathology of periodontal tissues. Stomatologija 2005;7:121-4.  Back to cited text no. 6
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American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33 Suppl 1:S62-9.  Back to cited text no. 8
Lewis JM, Morgan MV, Wright FA. The validity of the CPITN scoring and presentation method for measuring periodontal conditions. J Clin Periodontol 1994;21:1-6.  Back to cited text no. 9
Sheiham A. Public health aspects of periodontal diseases in Europe. J Clin Periodontol 1991;18:362-9.  Back to cited text no. 10
IDF Diabetes Atlas 10th Edition 2021. Available from: https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. [Last accessed on 2021 Dec 09].  Back to cited text no. 11
Hasan SM, Rahman M, Nakamura K, Tashiro Y, Miyashita A, Seino K. Relationship between diabetes self-care practices and control of periodontal disease among type 2 diabetes patients in Bangladesh. PLoS One 2021;16:e0249011.  Back to cited text no. 12
Kabisch S, Hedemann OS, Pfeiffer AF. Periodontitis, age-related diseases and diabetes in an endocrinological outpatient setting (PARADIES): A cross-sectional analysis on predictive factors for periodontitis in a German outpatient facility. Acta Diabetol 2022;59:675-86.  Back to cited text no. 13
Osterberg T, Carlsson GE, Sundh W, Fyhrlund A. Prognosis of and factors associated with dental status in the adult Swedish population, 1975-1989. Community Dent Oral Epidemiol 1995;23:232-6.  Back to cited text no. 14
Bourgeois D, Hescot P, Doury J. Periodontal conditions in 35-44-yr-old adults in France, 1993. J Periodontal Res 1997;32:570-4.  Back to cited text no. 15
Petersen PE, Ogawa H. Strengthening the prevention of periodontal disease: The WHO approach. J Periodontol 2005;76:2187-93.  Back to cited text no. 16
Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32:281-91.  Back to cited text no. 17
Susanto A, Manurung AS, Miranda A, Sopiatin S. Periodontal disease and treatment needs among patients with diabetes mellitus type 2 attending talaga bodas community Health center in Bandung City. Sci Dent J 2020;4:1-5.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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