J Clin Periodontol 2001; 28: 710–712 Copyright C Munksgaard 2001Printed in Denmark . All rights reserved

ISSN 0303-6979

Short CommunicationJoseph KatzDepartment of Oral Diagnosis, Oral MedicineElevated blood glucose levels inand Oral Radiology, Hebrew University –Hadassah School of Dental Medicine,Jerusalem, Israelpatients with severe periodontal

diseaseKatz J: Elevated blood glucose levels in patients with severe periodontal disease.

J Clin Periodontol 2001; 28: 710–712. C Munksgaard, 2001.

AbstractBackground, aims: The role of diabetes mellitus in various forms of periodontaldisease was investigated intensively in the past; some studies have also indicatedan impact of periodontal inflammation on diabetic balance. The purpose of thisstudy was to evaluate the reciprocal relationship between abnormal serum glucoselevels and elevated CPITN scores in non-diabetic patients.Material and Methods: 10,590 subjects were analyzed for normal and abnormal(higher than 120 mg/dl) serum glucose levels, their periodontal status reflected asCPITN was correlated with their glucose level category.Results: The results of the present study reflect a significant association betweenelevated blood glucose levels (higher than 120 mg/dl) and CPITN scores of 4.5

Key words: abnormal glucose levels;with an odds ratio of 2.46. periodontal diseaseConclusion: A strong association exists between abnormal serum glucose leveland periodontal disease as manifested by CPITN score. Accepted for publication 7 February 2001

The 2-way relationship between dia-betes mellitus (DM) and periodontaldisease has been studied intensively inthe past and has been subjected tolarge controversy (Chang et al. 1995,Culter et al 1999a, b). Very few studies,however, have investigated the role ofglucose blood levels in periodontal dis-ease patients and vice versa in a non-diabetic population. In a previous studyof more than 10000 military servicemen and women, we have shown thatblood glucose levels were positively as-sociated with periodontal disease (Katzet al. 2000a, b).The maximal change,however, although statistically signifi-cant, was relatively small, probably be-cause the results were the mean of thou-sands of single results and the glucoselevel distribution is not ‘‘normal’’ in thispopulation (most subjects have glucoselevels around 100 mg/dl). We have de-cided therefore, to include in these

studies, only categories of normal anddiseased states of glucose level, on theassumption that association betweenperiodontal disease and glucose bloodlevel will be reflected more significantlyin the extreme conditions.

Glucose levels were then divided into2 categories; less than 120 mg/dl, andabove 120 mg/dl; confident interval95%. No effect of gender on elevatedblood glucose was found, maybe be-cause of the relatively small number ofwomen with glucose levels higher than120 mg/ml, diastolic blood pressure hadno effect on the probability for elevatedglucose level. The effect of age, BMI,smoking status, and CPITN is shown inTable 1. The CPITN variable has thehighest effect on the probability for el-evated glucose level with an odds ratioof 2.46, when comparing subjects withsevere periodontal disease (CPITNΩ4.5) with subjects with a healthy peri-

odontium (CPITNΩ0.1). Interestinglythere was no difference between thesmoking and non-smoking groups;however, the probability of high glucoselevel was found to be 1.86¿ higher inthe past-smokers compared to non-smokers; this might reflect a long-stand-ing effect of heavy smoking for manyyears.

In the present study, we have shownthat subjects with severe and moderateperiodontal disease (CPITNΩ4.3 re-spectively) are at risk of developing ab-normal elevated glucose levels whichare (2.46 and 2.23, respectively) highercompared to subjects with healthy peri-odontium. This is shown in a large co-hort of healthy subjects with no diag-nosis of diabetes, which were undercontinuous medical observation.

Numerous studies conducted all overthe world have used the CPITN systemas a method for assessment of peri-

Hyperglycemia in periodontal disease 711

Table 1. Variables affecting blood glucose level

Lower UpperOdds confidence confidence

Variable Mode of effect ratio limit limit pΩvalue

age (years) with each year, the 1.097 1.069 1.126 ,0.0001chance for elevated glu-cose increases by 1.097

BMI with each unit, the 1.127 1.086 1.169 ,0.0001chance for elevated glu-cose increases by 1.127

smoking no difference between 1.277 0.855 1.908 0.23smoking and non-smok-ing

the chance for elevated 1.861 1.259 2.752 0.0018glucose level in pastsmokers is 1.861 timeshigher than non-smokers

CPITN the chance for elevated 2.46 1.86 3.2 0.0058glucose in subjects withCPITNΩ4.5 compared tosubjects with CPITNΩ0.1is 2.46

the chance for elevated 2.23 1.88 2.9 0.0001glucose level in subjectswith CPITNΩ4.5 com-pared to CPITNΩ2.3 is2.23

odontal disease and treatment needs inpopulation groups (Katz et al. 2000a,b, Baelum et al. 1995), despite the well-known limitation of this index. It hasbeen claimed that CPITN findings over-estimated both prevalence and severityof periodontal attachment loss amongyoung age groups, but underestimatedthese parameters among older subjects.

In a previous study (Bacic et al.1988), the CPITN was assessed in dia-betic patients. The authors showed thatperiodontal disease was more frequentand severe in diabetic patients as com-pared to non-diabetics. No differencesrelated to CPITN scores were found be-tween insulin-dependent and non-insu-lin-dependent diabetics. In the presentstudy, the effect of severity of peri-odontal disease on blood glucose levelswas also studied with the aid of theCPITN. In the entire study group, theeffect was noticed only in those with theworst CPITN score. In subjects withlower scores, no effect on mean bloodglucose levels was seen. This may sug-gest that studies examining the effect ofperiodontal disease on mean blood glu-cose levels in DM should make the dif-ference between severe periodontal dis-ease to milder situations. Since the localeffect is greatly diluted by the rest of the

body systems, its effect is noticed onlyif it is maximal.

Grossi & Genco (1998) proposed amodel for the 2-way relationship be-tween periodontal disease and DM. Inthis model, a self-feeding 2-way systemof catabolic response and tissue de-struction is created, resulting in moresevere periodontal disease and in-creased difficulty in controlling bloodsugar.

In a Position Paper of the AmericanAcademy of Periodontology (2000) it isstated: ‘‘The incidence of periodontitisincreases among diabetic subjects afterpuberty and as the patient populationages, Periodontal disease may be morefrequent and severe in diabetic individ-uals with more systemic complications.The increased susceptibility does notcorrelate with increased levels of plaqueand calculus. Collectively, the evidencesupports the theory that there is a re-lationship between the 2 diseases, espe-cially in patients with poorly controlleddiabetes or hyperglycemia’’.

The present study extends the evi-dence for the existence of a 2-way re-lationship between periodontal diseaseand elevated glucose level in a largepopulation. Further investigations as toexact the role of chronic infection in the

form of periodontal disease in bloodglucose metabolism are warranted.

Zusammenfassung

Erhohte Blutglukosespiegel bei Patienten mitschwerer ParodontitisHintergrund: Die Bedeutung von Diabetesmellitus fur verschiedene Formen der Paro-dontitis ist in der Vergangenheit intensiv un-tersucht worden. Einige Untersuchungen ha-ben auch auf den Einfluss parodontaler Ent-zundungen auf das diabetische Gelichgewichthingewiesen.Zielsetzung: Untersuchung der Wechselbezie-hung zwischen abnormalen Serumglukose-spiegeln und erhohten CPITN-Graden beinicht-diabetischen Patienten.Material und Methoden: 10.590 Personenwurden auf normale bzw. abnormale (,120mg/dl) Serumglukosespiegel untersucht undihre parodontalen Verhaltnisse gemessen alsGPITN-Grade mit der jeweiligen Serumglu-kosespiegelkategorie korreliert.Ergebnisse: Es wurde eine statistisch signifi-kante Assoziation zwischen erhohten Blut-glukosespiegeln (.120 mg/dl) und denCPITN-Graden 4/5 mit einer Odds Ratiovon 2.46 im Vergleich zu den CPITN-Graden0/1 beobachtet (pΩ0.0058).Schlussfolgerungen: Es besteht eine starkeAssociation zwischen abnormalen Blutglu-kosespiegeln und Parodontitis gemessen anCPITN-Graden.

Resume

Teneurs elevees en glucose sanguin chez les pa-tients avec parodontite severeOrigine, but: Le role du diabete melitus dansdiverses formes de la maladie parodontale aete etudie de maniere intensive dans le passe.Quelque etudes ont aussi indique l’impact del’inflammation parodontale sur la balancediabetique. Le but de cette etude a ete d’eva-luer la relation reciproque entre des teneursanormales en glucose serique et des scoreseleves CPITN chez des patients non-diabeti-ques.Materiaux et methodes: 10,590 personnes ontete analysees pour leur teneur en glucose se-rique normale ou anormale (c.-a-d. .120mg/dl). Leur etat parodontal evalue par lesscores CPITN ont ete mis en correlation avecleur categorie de teneur en glucose.Resultats: Une association significative a etemise en evidence entre des teneurs elevees englucose sanguin (.120 mg/dl) et des scoresCPITN de 4 et 5 avec un facteur eleve a 2.46.Conclusion: Une association importante exis-te donc entre une teneur anormale en glucoseserique et la maladie parodontale evaluee parels scores CPITN.

References

Bacic, M., Plancak, D. & Granic, M. (1988)CPITN assessment of periodontal disease

712 Katz

in diabetic patients. Journal of Periodonto-logy 59, 816–822.

Baelum, V., Manji, F., Wanzala, P. & Fejer-skov, O. (1995) Relationship betweenCPITN periodontal attachment loss find-ings in an adult population. Journal ofClinical Periodontology 22, 146–152.

Chang, C. J., Kao, J. T., Wu, T. J., Lu, F.H. & Tai, T. Y. (1995) Serum lipids andlipoprotein (a) concentrations in ChineseNIDDM patients. Diabetes Care 18, 1191–1194.

Cutler, C. W., Shinedling, E. A., Nunn, M.,Jotwani, R., Kin, B. O., Nares, S. & Iacop-ino, A. M. (1999a) Association betweenperiodontitis and hyperlipidemia: cause oreffect? Journal of Periodontology 70, 1429–1434.

Cutler, C. W., Machen, R. L., Jotwani, R. &Iacopino, A. M. (1999b) Heightened gingi-val inflammation and attachment loss intype 2 diabetics with hypelipidemia.Journal of Periodontology 70, 1313–1321.

Grossi, S. G. & Genco, R. J (1998) Peri-odontal disease and diabetes mellitus. Atwo-way relationship. Annals of Periodon-tology 3, 51–61.

Katz, J., Peretz, B., Sgan-Cohen, H. D., Zus-man, S., Horev, T. & Eldad, A. (2000a)Periodontal status by CPITN and associ-ated variables in Israeli permanent mili-tary population. Journal of Clinical Peri-odontology 27, 319–324.

Katz, J. & Chausho, G. (2000b) Relationshipof blood glucose level to CPITN and BMI

in Israeli permanent military population.Journal of Periodontology 71, 1521–1527.

Position Paper (2000) Diabetes and peri-odontal Diseases. Journal of Periodonto-logy 71, 664.

Address:

Joseph KatzP.O. Box 9618JerusalemIsrael

Fax: 972 2 6785126e-mail: kartzdr/internet-zahav.net.il