Journal of Interdisciplinary Dentistry

: 2018  |  Volume : 8  |  Issue : 3  |  Page : 81--86

Periodontal status among patients with type II diabetes in a newly developing country

Kholoud Zaidan1, Amal Alwadyaa1, Dhyeaa Al Khuzaei1, Hanaa Al Majed1, Badryia Al Lenjawi2, Hashim Mohamed3,  
1 Primary Care Corporation, Doha, Qatar
2 Hamad Medical Corporation, Doha, Qatar
3 Department of Family Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar

Correspondence Address:
Hashim Mohamed
Weill Cornell Medicine-Qatar, Doha


Background: Type II diabetes is becoming an epidemic among the population of Qatar. Patients with type II diabetes are more prone to periodontal disease. Metabolic derangement and poor quality of life are related to deterioration in the periodontal status. Objective: The aim of the current study is to estimate the prevalence of periodontal disease among patients with type II diabetes in Doha, Qatar. Study Design: This was observational cross-sectional study. Methods: One hundred and eighty patients with II diabetes were included in the study. Data were collected from participant medical records. The dental examinations consisted of a full-mouth assessment including the number of remaining teeth, assessment of periodontal status using the decayed, missing, and filled teeth (DMFT) index: To determine the impact of dental caries on the teeth. Similarly, the World Health Organization community periodontal index was used to determine the periodontal status of the patients. Information on metabolic parameters including glycosylated hemoglobin A1C values was collected from the participants' medical files. Results: A total of 49 (36.6%) participants had periodontal pocket of 4–6 mm, more than a third 46.6 (38.3%) of the participants had one tooth missing, around 52 (29%) patients had filled teeth, more than a third 72 (40%) of the participants had poor oral hygiene, two-third 120 (66.6%) had gingivitis, 71 (39%) periodontitis, and 66 (36.6%) dental caries. DMFT score showed that the majority of participants had decayed teeth 136 (75, 6%), 113 (63, 1%) had missing teeth, and 27 (15%) had teeth with total crown destruction. The mean DMF index was 6.3. Conclusion: Periodontitis was common among patients with type II diabetes in Qatar.

How to cite this article:
Zaidan K, Alwadyaa A, Al Khuzaei D, Al Majed H, Al Lenjawi B, Mohamed H. Periodontal status among patients with type II diabetes in a newly developing country.J Interdiscip Dentistry 2018;8:81-86

How to cite this URL:
Zaidan K, Alwadyaa A, Al Khuzaei D, Al Majed H, Al Lenjawi B, Mohamed H. Periodontal status among patients with type II diabetes in a newly developing country. J Interdiscip Dentistry [serial online] 2018 [cited 2018 Dec 13 ];8:81-86
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Full Text

 Clinical Relevance to Interdisciplinary Dentistry

Oral health of patients with type II DM is often overlooked in the developing world resulting in poor quality of life, dental loss and periodontal diseaseTimely screening and management of oral conditions among patients with type II DM will help prevent dental and gingival complications, lead to patient satisfaction and improve overall health outcome.


The state of Qatar, over the past three decades of economic transition, has witnessed a rapid rise in cardiovascular morbidity and mortality mainly due to diabetes. According to the International Diabetes Federation, Qatar has a national diabetes prevalence of 20.4% (Diabetes Atlas Fifth Edition, International Diabetes Federation, 2003),[1],[2] making the disease an epidemic and a national health and economic burden. Two recent studies were carried out in Sultanate of Oman and Saudi Arabia showing a higher prevalence of periodontal disease compared to the European countries among the general adult population.[3],[4] Till recently, dental care was not part of standards of practice among patients with diabetes in Qatar.

Diabetes is a common disorder with concomitant acute and chronic complications including oral manifestations which may include but not limited to gingivitis, periodontitis candidiasis, tooth loss, foul smell of the mouth, dental caries, xerostomia, tooth loss, lichen planus, burning mouth syndrome, salivary dysfunction, and taste impairment. Periodontitis is a relatively common and chronic condition of the tooth-supporting tissue secondary to bacterial deposits aggregating on tooth surface leading to plaque formation.[5],[6] Systemic inflammation-induced by periodontitis has been shown to aggravate systemic diseases including diabetes and cardiovascular system manifested in the buildup of athermanous plaques.[7],[8] Atherosclerosis is a slowly evolving process characterized by systemic inflammatory manifestations.[7] The prevalence of oral pathology and especially periodontitis remains unknown among patients with type II diabetes in Qatar. Uncontrolled diabetes coupled with bacterial infections may negatively impact the treatment of periodontitis. Dental implants have a lower success rate among patients with type II diabetes. Therefore, a vicious circle may ensue if poorly controlled diabetes is coupled with chronic periodontitis. The aim of this study was to estimate the prevalence of oral pathology among patients with type II diabetes living in Qatar.


A cross-sectional survey was carried out for 1 year from May 1 to February 2, 2014, at Um Gwailinah Health Center, Doha, Qatar. The World Health Organization's (WHO) community periodontal index (CPI) was used in our study by qualified dentists to assess periodontal status among participants. Dental caries was evaluated using the decayed, missing, and filled teeth (DMFT) index according to the WHO criteria, 1997. Ethical clearance was obtained from Hamad Medical Corporation (Medical Research Center, research proposal 11030/11).

Study population

The study population consisted of adult patients with type II diabetes attending um Gwailinah health center.


Respondents were selected via a stratified sampling technique followed by a clinical oral examination. Inclusion criteria included adult patients with type II diabetes. Exclusion criteria included individuals refusing to give consent, cancer or severely debilitating illness, documented alcohol, and drug abuse.

Data collection

A structured open-ended and closed-ended questionnaire was used to collect data including sociodemographic data, general health status, past medical history, comorbidities, medication intake, and any past dental history along with a questionnaire for recording clinical examination findings. An informed consent form was signed by the participants before inclusion in the study under bright light. Oral examination was carried out under bright light assessing the oral soft tissues and hard tissues including dental implants or appliances present.

A round ended graduated WHO periodontal probe was used to assess periodontal pockets. Oral pathologies and possible risk factors were assessed clinically using the following indices as follows:

The decayed, missing, and filled teeth index

It was utilized to assess the impact of dental caries on the teeth; we classified each tooth in one of: D denoting tooth decay. M denoting missing tooth either as a result of tooth extraction or other reasons. F denoting filled tooth as any tooth that has a permanent filling intact with no sign of caries lesion. N is the number of participants examined. DMF index = D+M+F/N+.[11]

The community periodontal index

It was utilized to assess the periodontal status of the participants. It involves using a periodontal probe to evaluate all the teeth after dividing the mouth into six sextants. Each sextant should consist of at least two functional teeth (i.e., nonextracted teeth). Toothless sextants with just a functional tooth were considered absent and marked with “X” on the data captured sheet.

The CPI index has five categories as follows:

0 = healthy1 = spontaneous bleeding2 = calculus3 = pocket depth of 4–6 mm4 = pocket depth >6 mm.[11]

Data analysis

Data obtained were analyzed using Statistical Package for Social Sciences Computer Software (SPSS 21.0, Inc., Chicago, USA). The statistical test used was the Chi-square with the significance level of P ≤ 0.05.


Sociodemographic status

During the study, the response rate was 95%; 180 participants aged between 35 and 75 years, with a mean age of 54 years, of which 63 (35%) males and 117 (65%) females. Study population were 85 (47.2%) of the participants were government workers, 62 (34.4%) were home makers, and 33 (18.3%) were laborers.

Comorbid conditions

Obesity 80 (44.4%), hypertension 60 (33.3%), osteoarthritis 42 (23.3%), and peripheral neuropathy 38 (21.1%) [Figure 1].{Figure 1}

Oral hygiene status

More than a third 72 (40%) of the participants had poor oral hygiene, 65 (36.1%) had good oral hygiene, and 53 (29.4%) were fair.

More than a third of participants (39.1%) presented with plaque after scrabbling, the majority (43.4%) had visible dental plaque, and 14.6% had abundant plaque [Figure 2].{Figure 2}

Oral pathologies

Two-third 120 (66.6%) had gingivitis, 71 (39%) periodontitis, 66 (36.6%) dental caries, and 19 (10.5%) tooth wear [Table 1].{Table 1}

Periodontal status

A total of 49 (36.6%) participants had periodontal pocket of 4–6 mm, eighteen (10%) had mobile teeth, 43% bleeding on probing, and 14% subgingival calculus [Figure 3].{Figure 3}

More than a third 54 (33%) did not have any carious tooth, 12 (14%) had one missing tooth, and 11 (16%) had two missing teeth. More than a third 46.6 (38.3%) of the patients had one tooth missing, 14 (19.6%) have lost two teeth, and 19 (9.3%) had more than three missing teeth. With regards to filled teeth, around 52 (29%) had filled teeth see [Table 2].{Table 2}

Decayed, missing, and filled teeth score

The majority of participants had dental caries 136 (75, 6%), 113 (63, 1%) had missing teeth, and 27 (15%) had teeth with total crown destruction. The mean DMF index was 6.3.


Oral hygiene status

The oral hygiene status of the study participants is far below standards. It is worth noting that dental services at primary health-care centers in Qatar is almost free, near to our patient living places and only 2%–5% of medication actual price is incurred on the patient. However effective patient education, the culture of routine dental visits is not practiced in Qatar. Similar to studies in Africa and Europe, patients usually visit the clinic only when they have pain or an emergency dental problem,[9],[10] This can be partly explained by the phobia of visiting the dentists where the pain is almost guaranteed in any intervention. Furthermore, the silent and prolonged nature of dental caries and periodontal disease make patients wait for long periods until pain strikes or foul odor of the mouth is noticed by family members or friends.

Periodontal status

Similar to other studies in neighboring countries and Asian countries including Vietnam,[11] there was poor periodontal status among our participants manifested in high calculus deposits and a high percentage of periodontal pockets of 4–6 mm. Lack of brushing, inappropriate brushing technique, poor oral hygiene, and lack of regular dental follow-up are few reasons behind the current situation. Uncontrolled diabetes, on the other hand, is a major factor contributing to the poor periodontal status in our patients.

It is well documented that chronic periodontal disease ultimately results in the ongoing destruction of the supporting tissues of the teeth, pocket formation, recession, which may lead to extensive destruction of alveolar bone ultimately leading to tooth loss. Periodontal disease is documented as one of the main causes responsible for tooth loss among patients with diabetes.[12],[13],[14],[15],[16]

A recent meta-analysis of four studies concluded that individuals with diabetes have a 2-fold higher risk of developing the periodontal disease compared to those without diabetes.[17]

The susceptibility to periodontal diseases among patients with uncontrolled diabetes mellitus (DM), is linked to alterations in host response, high inflammatory state, collagen metabolism, and vascularity. Patients with uncontrolled type 2 DM manifest an exaggerated inflammatory response to the bacterial challenge of periodontitis. An exaggerated inflammatory response coupled, altered immune response, impaired wound healing, and repair may exaggerate the inflammatory response resulting in periodontal tissue destruction in those patients.[18],[19],[20],[21] Many controlled clinical trials have shown that patients with diabetes have a higher prevalence of periodontal diseases compared to healthy individuals.[19],[22],[23] Vice versa, severe periodontitis may increase the risk of poor glycemic control.[24],[25]

In individuals with type II diabetes, the host inflammatory response seems to be the critical factor for susceptibility to and severity of periodontitis.[26],[27] Similarly, there is evidence to suggest that periodontitis-induced bacteremia will cause increased levels of reactive oxygen species and serum proinflammatory cytokines, leading to increased insulin resistance. Qatar, over the past 2 years has established an almost 95% paperless digital records and coupled with the American Diabetes Association guidelines which are the official guidelines adhered to by family physicians practicing in Qatar may tilt the balance in favor of a more proactive health-care delivery similar to screening for retinal and renal diseases.

Dental status

Similar to studies elsewhere including Africa and Europe, our study revealed a rather high mean DMFT score[12],[20] along with a high prevalence of tooth decay.[4],[10],[21],[22] However, the prevalence of tooth decay is not uniform in developed countries. Canada, for example, has a low prevalence of tooth decay[28] compared to Norway.[20] Many factors may influence this discrepancy in the prevalence of tooth decay including the level of education, fluoridation of water, access to oral health facilities, electronic versus paper files system, recall systems, medical insurance and reimbursement, dietary habits, and genetic factors.

Missing teeth, teeth with total crown destruction, and filled teeth

Recent data have revealed the association between tooth loss, periodontal disease, and many systemic diseases including diabetes, cancer, and cardiovascular disease. Our data revealed a high level of periodontal in accordance with other studies worldwide, especially in older populations.[17],[29] Estimates of the Global prevalence of severe periodontal disease may vary from 10% to 15%, although up to 90% of individuals may be affected by the milder periodontal disease, including gingivitis.[17],[29],[30],[31] Many factors may contribute to the development of periodontal disease including race, aging population, gender,[17] obesity,[32],[33] smoking, and nutrition.[31] In addition, limited adult periodontitis suggests that approximately one-half of cases may be heritable.[34]

The proportion of patients with missing teeth our study is high as compared to another study conducted out in France where the proportion of edentulousness was 26.9%.[24] This could be because of the high prevalence of diabetes, obesity in Qatar, where type II diabetes has reached almost 20.4% and obesity 40% along with lack of proper oral hygiene and periodic recall for the screening of periodontal diseases.

The booming population of Qatar along with the high influx of expatriates place a huge burden on dental services in the country leading to long delays in dental appointments in tertiary care which make affluent people and those with medical insurance seek private treatment, whereas those with low socioeconomic status have to wait for long periods of time to be seen in tertiary dental care. This delay undoubtedly leads to worsening of the situation of periodontal status, especially in those with diabetes. Furthermore, the impact of DM on periodontal disease has been shown to be independent of other major risk factors.[17]


The high prevalence of periodontal disease in our study is alarming, especially when coupled with systemic diseases such as metabolic syndrome and cardiovascular disease. This finding should prompt stakeholders into designing a more proactive dental care involving effective dental education, optimal glycemic control, weight reduction, and periodic screening for dental status among patients with type II diabetes, especially nowadays where an electronic system is currently in place.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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