Periodontal Status and Gestational Diabetes Mellitus: A Case-Control Study

  


    
 

    
 

    
DMG with adverse outcomes


      n=46

    
DMG withoutadverse outcomes


      n=53

    
p

  

  


    
Plaque Index


      PI = 20 %


      PI < 20 %

    
n (%)

    
27    (58.7)


      19    (41.3) 

    
 

      
28    (52.8)


        25    (47.2)

    
 

      
0.558a 

  

  


    
Bleeding    on Probing


      BOP = 10    %


      BOP <    10 %

    
n (%)

    
37    (80.4)


      9    (19.6)

    
41    (77.4)


      12    (22.6)

    
0.709a 

  

  


    
Pocket    Probing Depth


      Mean PPD    (mm)

    
Mean (SD)

    
2.35    (0.38) 

    
2.31    (0.33)

    
0.723c 

  

  


    
Clinical    Attachment Level


      Mean CAL    (mm)

    
Mean (SD)

    
2.40    (0.39)

    
2.38    (0.35)

    
0.955c 

  

  


    
Periodontal    status


      Periodontal    health


      Gingivitis


      Periodontitis*

    
 

      
n (%)

    
 

      
8 (17.4)


        10(21.7)


        28 (60.9)

    
 

      
6 (11.3)


        5(9.4)


        42 (79.3)

    
 

      
0.59a 

  

  


    
a    Χ2 


      c    U Mann Whitney 


      * Defined according to CDC-AAP criterion 

  

Table 4: Periodontal condition in GDM participants with and without adverse pregnancy outcomes.

Discussion

Our study shows that pregnant women who developed gestational diabetes during their pregnancy, in addition to being older and with a lower level of education, had a worse periodontal condition than non-diabetic pregnant women. This is because they had fewer teeth, a greater presence of gingival inflammation and periodontitis, as well as a higher average of PPD and CAL. Maternal age, educational level and the presence of periodontitis are independent risk factors for GDM.

The results of this study showed a significant association between having a family history of first degree diabetes and developing GDM. Some studies coincide with these findings [17] while others did find a relationship [18]. As far as BMI is concerned, a BMI ≥ 30 Kg/m² is considered to be a risk factor for developing GDM [19]. Some studies observe the association of BMI with women who had GDM [17,18,20-22]. Our results initially show that a higher BMI occurs among gestational diabetics, however, when performing logistic regression its importance disappears. This could be due to sample limitation. In fact, only 30 patients had a BMI greater than 30, of which 19 had GDM and 11 did not, Χ2 = 1.96, p= 0.16. Our sample size is probably responsible for not including it as a risk factor.

The presence of bacterial plaque is the main risk factor for PD, so it could act as a confounding factor between periodontal parameters and GDM. In this study, it was observed that there were no significant differences in PI between cases and controls, so we ruled out dental plaque as a possible confounder that could exacerbate the relationship between PD and GDM. Bagis et al. [22] also found no differences in PI between the two groups. However, other authors did observe significant differences [21].

Other factors that did not show a significant relationship with GDM and agreeing with what has been observed in the literature are smoking [17,20] and brushing frequency [17,18,23]. When analyzing bleeding on probing between cases and controls, statistically significant differences were found. There were more pregnant women with GDM who presented gingival inflammation than in the control group (75.7% vs 56.8% respectively). These results agree with those found by other authors [17,18,21,22]. Kumar et al. [24] in their work concluded that the incidence of GDM was significantly higher in women with gingivitis, periodontitis and periodontal disease in general compared to women with healthy gums, consistent with our findings.

Regarding the number of teeth, the gestational diabetics showed a significantly lower number than the controls. These results are in line with other studies [20,21]. In this study, the mean periodontal parameters of PPD and CAL are statistically related to GDM. We found significant differences in the mean PPD between the patients of the two groups (p=0.001). We agree with others in the existence of a significantly higher mean PPD in diabetic pregnant women than in controls [17,18,21]. However, Bagis et al. [22] find no relationship between mean PPD and the presence or absence of GDM. Regarding the mean CAL in patients with GDM and without GDM, we found significant differences (p=0.013). Other works such as that of Chokwiriyachit et al. [18] or Ruiz et al. [21] agree with these findings.

The educational level maintained significant differences with the GDM. In this work, it is an independent risk factor for GDM so that, the higher the level of education, the lower the prevalence of GDM. Other works did not take this factor into account [18,21] or found no relationship.[17,20,23]. The level of education can be considered a proxy for the economic situation. A higher level of education is generally associated with a higher economic level, greater health education and access to health care.

Older age is a risk factor for gestational diabetes [17,20,21]. In this study, the women with GDM were significantly older than the pregnant women in the control group. In fact, in our casuistry, age appears as a predictor OR 1.14, p <0.001. The other risk factor that we observed in our study is the presence of periodontitis OR = 2.43, p <0.01, observation confirmed by others [17,18,21]. Interestingly, two systematic reviews, published in the same year, showed contradictory results. Esteves Lima et al. [12] concluded that the scientific evidence could not demonstrate a positive association between periodontitis and GDM. In contrast, the results of the meta-analysis by Abariga and Whitcomb [13] suggested those patients with periodontitis were more than twice as likely to develop GDM, a figure similar to our estimate risk. In the same sense and more recently, Kumar et al [24] observed an association between periodontal disease and GDM and a higher risk of developing preeclampsia, with an adjusted HR of 2.85, 95% CI = 1.47 to 5.53. Esteves Lima et al. [12] observed a significant association in the meta-analysis of 4 cross-sectional studies (OR 1.67, 95% CI 1.20 to 2.32) and also in two case studies (OR 2.66, 95% CI 1.52 to 4.65), while when in this last group they integrate their own study, the significance of risk disappears (OR 1.69, 95% CI 0.68 to 4.21). These same authors point out the difficulty in the study given the clinical, methodological and statistical differences between the studies.

Scientific evidence from numerous studies indicates that diabetes mellitus (DM) and PD are bidirectionally related [25]. In other words, being diabetic is a risk factor for the onset and progression of PD and, although there is less scientific evidence, periodontitis could increase the risk of developing DM and compromise glycemic control in patients with DM. Therefore, in this work we have tried to assess the existence of a possible bidirectional association between GDM and PD. After an extensive review of the literature, we are not aware of studies that analyze whether patients with GDM and worse periodontal condition have worse glycemic control and require more frequent insulin treatment. To study this possible association, we separated the 111 patients with GDM into two groups: insulin dependent (n=32) and non-insulin dependent (n=79) following the ACOG classification. When analyzing the influence of the periodontal parameters: PI, BOP, PPD and NIC and the PD status on the glycemic control of GDM, no differences were observed at the 95% confidence level between insulin-dependent and non-insulin-dependent patients. Therefore, we cannot say that pregnant women with GDM and worse periodontal condition show lower glycemic control than patients with GDM and periodontal health. Other studies should analyze the impact of the periodontal condition on the glycemic control of gestational diabetes.

In this work we have recorded perinatal complications (preterm birth, LBW, PROM, preeclampsia, macrosomia, and IUGR). When reviewing the literature, we verified that only two studies collect the adverse pregnancy outcomes. In the one by Dasanayake et al. [26] where perinatal complications were studied with GDM but not with PD, this author found that pregnant women with GDM presented more PROM. However, this difference was not observed in our study. The other study that analyzed perinatal complications with PD and GDM was that of Kumar et al. [24] who established a relationship between PD and GDM and an increased risk of developing preeclampsia due to this association. In our study we also found that pregnant women with gestational diabetes had a significantly higher risk of preeclampsia. However, our results showed no relationship between preeclampsia and PD. Interestingly, there are studies in which the treatment of periodontitis during pregnancy does not reduce the adverse obstetric effects associated with it, such as prematurity or low birth weight [27,28]. We found no association between the existence of periodontitis and prematurity or preeclampsia. Others do find it, with OR for premature birth and/or low birth weight between 2.04 to 4.19 [29].

Limitations

Among the main limitations of the studies of GDM and periodontitis is the discrepancy of the definitions used to diagnose both GDM and periodontitis. In this work, in addition to analyzing the mean periodontal parameters of PPD and CAL, the CDC-AAP [16] criteria have been used. Although an association between periodontitis and GDM is observed in this study, its cross-sectional design does not allow establishing causality judgments. Whether periodontitisis a risk factor for GDM or whether having GDM or a prediabetic metabolic situation would increase the prevalence and severity of periodontitis.

The number of patients examined, despite being the highest of most relevant publications that aim to relate PD to GDM [17,18,20,24,26] so far, is a limiting factor since it could be insufficient or less likely to find significant differences when analyzing low-prevalence diseases such as preeclampsia or premature birth, which some authors relate to the periodontitis. Another possible limitation is the non-blinded study design.

Conclusions

Patients who develop gestational diabetes have a worse periodontal condition than unaffected ones. The risk of GDM can be estimated in our sample based on periodontitis, age and educational level.

A worse periodontal condition does not imply that pregnant women with GDM require more insulin treatments than gestational diabetic pregnant women with better periodontal status.

Gestational diabetic women with periodontal pathology do not have more perinatal complications than pregnant women with GDM and better periodontal condition.

Acknowledgements

We thank IIS (Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe de Valencia) for authorizing and facilitating the clinical study of all the patients. This work has not received external funding. The authors declare no conflicts of interest.

Ethics Approval and Consent to Participate

All patients received the information sheets and signed the consent before their participation in the study. They were also informed of the confidentiality of the data collected following the protocol of the Organic Law on Data Protection (LOPD) 15/1999. The study was carried out following the Declaration of Helsinki, and authorized by the Ethics Committee for Biomedical Research and the Research Commission of the Hospital La Fe in May 2017.

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