Tooth Loss Patterns in Patients with Periodontitis and Diabetes Mellitus

Aim: Periodontitis is an inflammatory, multifactorial disease which results in destruction of supporting tissue and bone thereby resulting in loosening of the tooth. Tooth loss is one of the major oral issues faced by elderly patients. Thus the present study aimed to investigate the prevalence of tooth loss among periodontitis patients. Methodology: Data collection was conducted from June 2020 to March 2021 among 200 periodontitis patients with diabetes mellitus based on the record management system software to analyse the most frequent missing tooth at the time of first visit. Frequency of maxillary anterior, maxillary posterior, mandibular anterior and mandibular posterior tooth loss was assessed in the study. Results: Among the frequency distribution the mandibular posterior tooth loss was the most common among periodontitis with diabetes patients. In case of anterior tooth loss the results were almost similar with 16% of maxillary anterior tooth loss and 17% in case of mandibular anterior tooth loss. Male subjects presented with more missing teeth in mandibular posterior tooth region when compared to females but not statistically significant (p>0.05). Original Research Article Cibikkarthik et al.; JPRI, 33(60B): 3827-3835, 2021; Article no.JPRI.78501 3828 Conclusion: The present study results showed that there is no significant association between sex and maxillary anterior, mandibular anterior, maxillary posterior and mandibular posterior tooth loss (p>0.05). The present study showed that mandibular posterior tooth loss was most frequent among periodontitis with diabetes mellitus patients.


INTRODUCTION
Diabetes mellitus is a systemic disease characterized by increased blood glucose levels and abnormalities of lipid metabolism due to absence or decreased level of insulin. It affects all the body organs and their functions either directly or indirectly. Every dentist should have a basic understanding of the etiopathogenesis, oral and systemic manifestations of this disease [1]. Periodontitis is most commonly a consequence of extension of the gingival inflammation into the underlying supporting structures of the periodontium, initiated by the presence of plaque and its products on the surfaces of the teeth and the adjoining structures [2]. Tissue destruction in periodontitis results in the breakdown of the collagen fibers of the periodontal ligament, resulting in the periodontal pocket between the gingiva and tooth [3]. The causes of tooth loss vary with geographical location, culture and even time. Studies reported more teeth lost due to periodontal reasons compared with dental caries [4]. Diabetes and periodontitis influence the clinical outcome of each other and control of both influences the clinical improvement of each [5].
Majority of well-controlled studies show a higher prevalence and severity of periodontal disease in diabetics than in non-diabetics with similar local irritation including greater loss of attachment, greater alveolar bone loss, increased bleeding on probing, and increased tooth mobility resulting in tooth loss [6]. Most striking changes in uncontrolled diabetes are reduction in defense mechanisms and increased susceptibility to infection leading to destructive periodontal disease and which results in tooth loss [7]. Diabetes has impaired defense mechanisms involving micro-and macro-vasculatures. The increased susceptibility to infection and reduced healing capacity with altered collagen metabolism may explain the increased level of periodontal destruction [8].
According to the World Health Organization adults should have a minimum of 21 functional teeth to provide the ability to experience a good dietary intake without the need of dentures. It has been shown that edentualism reduces the quality of life [9]. Potential risk factors for edentulism are low level of education, older age, gender and marital status. Lower income has also been suggested to be a risk factor for tooth loss [10].

Study Setting
This study was carried out in a university setting which consists of subjects predominantly South Indian population. Advantages of the study include available data and similar ethnicity. Disadvantages of this study is the fact that it is a unicentre study and the geographic location trends are not assessed. Number of people involved are 3 reviewers-a guide, a researcher and a reviewing expert.

Sampling
This is a retrospective study in which the samples were considered from the time period of June 2019 to March 2020. Case sheets reviewed for the research include patients with tooth loss patterns. Cross verification of the required samples was done by the reviewing expert. Measures were taken to minimize the sampling bias. These are inclusion of only clear and readily available data followed by simple random sampling. Both internal and external validation was also obtained to carry out the study.

Data collection/Tabulation
Data required for this study was procured by reviewing the patient records of about 86000 patients visiting the dental college. The samples were collected from June 2019 to March 2020. Dental Information Archiving Software is the database system used in college to record all the details of the patient, which include their demographic data, photographs, diagnosis and treatment reports The required data i.e, periodontitis patients with diabetes mellitus presented with missing teeth were collected and entered in a methodical manner in an excel sheet for the tabulation of data and further statistical analysis data was validated by 1-2 external reviewers and all the nonspecific, unclear or incomplete data were excluded from the study.

Statistical Analysis
Statistical software used for analysis is the SPSS (statistical package for the social sciences) which is designed by IBM and Chi-square statistical test was used to determine the association of missing teeth region with gender. Independent variables include ethnicity, gender, age. Dependent variables include diabetes mellitus, tooth loss patterns, periodontitis.

DISCUSSION
From the graphs it was seen that male population is 67.3% and the female population is 32.6% (Fig. 1) molar of them were missing in the maxillary arch on the right side (Fig. 2). 4.52% of central incisor, 7.04% of lateral incisor, 9.55% of canine, 10.05% of 1 st premolar , 10.05% of 2 nd Premolar , 13.07% of 1 st molar, 33.67% of 2 nd molar , 12.06% of 3 rd molar were missing in the maxillary arch on the left side (Fig. 3) 6.03% of central incisor, 6.53% of lateral incisor, 5.03% of canine, 13.07% of 1 st premolar, 14.57% of 2 nd Premolar , 27.14% of 1 st molar, 13.57% of 2 nd molar ,14.07% of 3 rd molar were missing in the mandibular arch on the right side (Fig. 4) (Fig. 5). Fig. 6 denotes 14.46% missing teeth in the maxillary anterior region, 32.66% of missing teeth in the maxillary posterior region, 17.09% of missing teeth in the mandibular anterior region and 33.67% of missing teeth in the mandibular posterior region. 12.56% of males and 4.02% of females had missing teeth in the maxillary anterior region, 21.61% of males and 11.06% of females had missing teeth in the maxillary posterior region. 8.54% of males and 8.54% of females had missing teeth in the mandibular anterior region. Males (24.62%) had more missing teeth in the mandibular posterior region when compared to females (9.05%) (Chi-square test shows p value= 0.243 (p>0.05), hence statistically not significant).
Montandon et al. [30] showed that the prevalence of tooth loss in male population is due to periodontitis with diabetes mellitus and posterior tooth loss is the most common which is similar to our study results where the mandibular posterior tooth loss was most frequent among periodontitis patients with diabetes mellitus.
Indurkar et al. [31] showed that maxillary posterior tooth had more amount of bone defects while evaluating CBCT, thereby shown to be the most commonly affected teeth region by periodontitis which was contradictory with our study results where mandibular teeth region were more affected among periodontitis patients with diabetes mellitus. Ikimi et al. [32] showed that among Nigerian patients the tooth loss was more frequent among diabetic patients than among the systemically healthy patients with periodontitis. Rolfing CL et al. suggested that older patients may present with greater duration of the disease and consequently have also been exposed to periodontopathogens for a longer period, presenting signs of periodontal disease, and a faster disease progression leading to tooth loss. It can also be hypothesized that patients with diabetes who are negligent with their overall health could also be negligent with their oral health, and present with more complications associated with diabetes.

CONCLUSION
Within the limitations of the present study the results showed that mandibular tooth loss was most frequent among periodontitis with diabetes patients. Though mandibular posterior missing was more commonly missing in male population when compared to females, the gender is not significantly associated with tooth loss in periodontitis patients with diabetes mellitus. The periodontal condition in diabetic patients was poor, presenting periodontitis in most cases. This can be a major cause of tooth loss in diabetic subjects and requires special attention by clinicians.

CONSENT
It is not applicable.

ETHICAL APPROVAL
Ethical Approval of the study is by the ethical board of Saveetha University.

ACKNOWLEDGEMENT
This research was done under the supervision of the Department of research of Saveetha dental college and hospitals. We thank our colleagues who provided insight and expertise that greatly assisted the research. The present project is supported by Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University and Mahendra Enterprises.

COMPETING INTERESTS
Authors have declared that no competing interests exist. and biological applications of biosynthesized silver nanoparticles with chitosan-fucoidan coating.