Baixe Braz JOral Sci - 2011 - Vol11 - Issue1 - p47-51 e outras Notas de estudo em PDF para Odontologia, somente na Docsity! Braz J Oral Sci. 11(1):47-51 Received for publication: November 11, 2011 Accepted: February 08, 2011 Original Article Braz J Oral Sci. January | March 2012 - Volume 11, Number 1 Clinical effects of supragingival plaque control on uncontrolled type 2 diabetes mellitus subjects with chronic periodontitis Andrea Son1, Claudia Pera2, Paulo Ueda2, Renato Corrêa Viana Casarin3, Suzana Peres Pimentel3, Fabiano Ribeiro Cirano3 1DDS student, Paulista University, Brazil 2DDS, MSc student, Periodontics Division, Paulista University, Brazil 3DDS, MSc, PhD, Professor, Periodontics Division, Paulista University, Brazil Correspondence to: Fabiano Ribeiro Cirano Periodontics Division, Paulista University Av Dr Bacelar,1212, Vila Clementino, São Paulo, São Paulo - CEP 04026-002 Phone/Fax: +55 11 55864000 E-mail: cirano@unip.com.br Abstract Aim: To determine the clinical changes occurred in chronic periodontitis patients presenting uncontrolled type 2 diabetes mellitus after a supragingival plaque control period. Methods: Subjects presenting generalized chronic periodontitis were divided into two groups: Non-diabetics (n=20) – healthy subjects presenting chronic periodontitis; and Diabetics (n=14) – subjects with uncontrolled type 2 diabetes mellitus presenting chronic periodontitis. All subjects went through 28 days of supragingival plaque control - ST - (including prophylaxis, calculus removal, extraction of hopeless teeth and oral hygiene instructions) and were evaluated at baseline and after 28 days by the following parameters: Full-Mouth Plaque Score (FMPS) and Full-Mouth Bleeding Scores (FMBS), Periodontal Probing Depth (PPD), Gingival Recession (GR) and Clinical Attachment Level (CAL). ANOVA/Tukey’s test and Student’s t test were used for data analysis. Results: No statistically significant differences (p>0.05) between groups were observed at baseline for any parameter. Both groups presented a significant reduction in FMPS and FMBS after 28 days (p<0.05), but no statistically significant difference was found (p>0.05) between groups. Clinically, only the Non-diabetic group showed a significant improvement after ST, in PPD of initially deep pockets (p<0.05). However, no change in the clinical parameters was observed in the diabetic subjects (p>0.05). Conclusions: It may be concluded that uncontrolled diabetes mellitus reduces periodontal changes in the supragingival plaque control regimen of subjects presenting with chronic periodontitis. Keywords: diabetes mellitus, plaque control, chronic periodontitis. Introduction Chronic periodontitis results from the presence of complex microbial communities in the subgingival sulcus1, and diabetes mellitus, especially if poorly controlled, increases significantly risk for development of extensive and severe diseases2. Hyperglycemia and resultant advanced glycation end product formation, which is one of several pathways thought to lead to the vascular complications with diabetes, are also involved in the pathophysiology of periodontitis in diabetic subjects3, leading to an imbalanced release of pro- and anti-inflammatory cytokines4-6 and osteoclastogenesis-related factors7. Braz J Oral Sci. 11(1):47-51 48 Despite the differences in pathogeneses, biofilm still remains the primary etiologic factor for the development of a destructive periodontal disease2. Thus, the primary goal of periodontal therapy is to target the subgingival biofilm present in periodontally diseased sites that are associated with the progressive destruction of the supportive periodontal tissues. It is well documented that conventional therapy, i.e., subgingival scaling and root planning, is effective in achieving this goal. However, supragingival plaque control appears to have a significant effect on clinical and microbiological characteristics of periodontal pockets, which could be associated with the close relationship between those environments8. Previous studies have evaluated the relationship between supragingival plaque control and clinical and microbiological effects on subgingival areas, reporting a positive effect in systemically healthy subjects with periodontitis, i.e., a reduction in probing depth and some periodontal pathogens and preventing re-colonization9-11. However, conflicting results of the impact of supragingival dental biofilm control on clinical features in untreated periodontal sites are found in the literature12-14. In this context, there is an interest in the possible effect of supragingival biofilm control on the subgingival environment in untreated periodontitis sites in diabetic patients, since, in previous studies, these patients presented with some altered biofilm compositions, with a higher prevalence of periodontal pathogens. Thus, the aim of the present study was to determine clinical changes in type 2 diabetic patients after 28 days of strict supragingival plaque control compared with non-diabetic patients. Material and methods Population Screening Initially, manuscript design was approved by the institutional Ethics Committee (protocol number 014/09). Eligible patients were selected from those referred to the Graduate Clinic of Paulista University, Brazil. All patients received a complete periodontal examination, including full mouth periodontal probing, radiographic examination, and complete clinical interview. Moreover, type 2 diabetic patients were sent to the clinic by Vila Mariana Health Center (HCVM), São Paulo, Brazil after being diagnosed using the Fasting Plasma Glucose (FPG) > 110 mg/dL and the glycated hemoglobin (Hba1c) > 7% in two different examinations. All diabetic subjects were followed by a physician at HCVM. Subjects who did not have diabetes but who presented with periodontitis were also selected in order to compare of the clinical response of both types of patients. The study inclusion criteria were the following: Diagnosis of chronic periodontitis, according to the criteria of the 1999 international classification15; at least 8 teeth with a periodontal probing depth (PPD) > 5 mm and bleeding on probing; presence of at least 20 teeth; and good general health. Patients who were pregnant or lactating, required antimicrobial pre- medication for the performance of periodontal examination and treatment, received a course of periodontal treatment within the last 6 months, smokers, those under use of long- term antiinflammatory drugs, suffered from any other systemic diseases (cardiovascular, pulmonary, liver, and cerebral diseases), or had received antimicrobial treatment in the previous 3 months were excluded from the study. The sample size was determined after considering data in the literature and was aimed at obtaining a minimum power value of 0.8 to detect a difference and 0.8 mm between groups in clinical attachment level (CAL) (primary variable). A blinded and calibrated examiner was used (intra-class correlation for CAL) = 94% in a parallel design. Supragingival Plaque Control therapy (ST) After full mouth examination and participants’ informed consent, the patients in both groups received a full mouth prophylaxis, supragingival calculus, and biofilm removal using Gracey curettes, ultrasonic scaler, bicarbonate spray, and dental floss. Also, condemned teeth were extracted and biofilm retentive factors were removed. Moreover, the patients were individually instructed on how to perform oral self- care, including the Bass technique, inter-dental flossing, and tongue brushing. All subjects received a standard fluoride dentifrice, toothbrushes, and dental floss as necessary and were asked to perform complete oral self-care hygiene at least twice a day. A week after this first instruction session, patients returned for reinforcement of the oral self-care instructions. Twenty-eight days after ST, clinical re-evaluation was performed. Groups Subjects were distributed to the following groups: Diabetics (N=14): composed of individuals presenting with uncontrolled type 2 diabetes mellitus and generalized chronic periodontitis and Non-Diabetics (N=20): composed of individuals presenting with generalized chronic periodontitis. Clinical Parameters The following clinical parameters were assessed immediately before and 28 days after plaque control therapy using a PCP-15 periodontal probe (Hu-friedy, Chicago, IL, USA): Full-mouth Plaque Index (FMPI)16 and Full-Mouth Bleeding Score (FMBS)17; represented by the percentage of positive sites; PPD – Distance from the bottom of the pocket to the gingival margin); Gingival Recession (GR – distance from the gingival margin to cement-enamel junction); CAL – distance from the bottom of the pocket to cement-enamel junction) Glycemic status A single laboratory performed the glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) tests in order to confirm Diabetes mellitus status. HbA1c (%) was measured using high-performance liquid chromatography, and FPG was performed using the glucose oxidase method. For Clinical effects of supragingival plaque control on uncontrolled type 2 diabetes mellitus subjects with chronic periodontitis