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Oral complications of Type 1 diabetes mellitus in a non-smoking population

Robertson, Douglas Paul (2011) Oral complications of Type 1 diabetes mellitus in a non-smoking population. PhD thesis, University of Glasgow.

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Abstract

Type 1 diabetes mellitus (T1DM) is a complex metabolic condition that results in hyperglycemia due to insulin deficiency (Daneman, 2006). Diabetes has a range of effects on almost every system in the body including the kidneys, the eyes, the cardiovascular system, the genito-urinary system, the gastro-intestinal system and the nervous system (Daneman, 2006). The effects of this ondition are widespread and have a significant impact both on life expectancy and the quality of life of individuals suffering from diabetes (Scottish Diabetes Survey Monitoring Group, 2011). The impact of diabetes on oral health has been investigated over many decades, however, the conclusions have been varied and study design has not always been adequate (Mealey et al., 2006; Khader et al., 2006; Chávarray et al., 2009). Research presented in this thesis is largely the result of a cross-sectional clinical study examining the oral cavities of non-smoking T1DM patients, funded by the Chief Scientist Office of the Scottish Government. The clinical part of the study took place between January 2006 and May 2009 in Glasgow Dental Hospital. Chapter one provides an introduction and narrative review on the subject of T1DM, periodontal disease, and the various other reported oral manifestations of diabetes mellitus. The methods for measuring general and oral health related quality of life outcomes are also discussed. Chapter one reveals some of the inadequacies of studies nvestigating the link between T1DM and oral disease to date and ontextualises the studies presented in this thesis. Chapter two presents the main periodontal findings of a large cross-sectional study. 112 non-diabetic subjects and 203 subjects with type 1 diabetes were examined. 203 diabetic patients were divided into well controlled and poorly controlled groups based on their average blood sugar levels over the previous two years. 169 were poorly controlled. (PCD). Those with T1DM, (especially those with poor glycaemic control) had a greater extent and severity of periodontitis than those without diabetes. There was also some evidence that never smoking T1DM patients were more likely to have periodontal disease than non-diabetic subjects. The odds ratio (OR) was 1.43 [0.74 to 2.75] (p = 0.29) for all T1DM patients and 1.58 [0.75 to 3.33] (p = 0.23) for PCD. This difference remained even after the multivariable analysis took into account age, gender and lifestyle including: body mass index of the subject; whether they had smoked in the past; whether they attended a dentist; their level of education and how deprived the area they lived in was. Chapter three presents an analysis of the impact of age, HbA1c, and duration on the expression of periodontal disease in T1DM subjects. Cross-tabulations and multivariable logistic regression analysis was performed on the periodontal data from T1DM subjects and non-diabetic subjects in order to determine the relationship between age, HbA1c and duration, and periodontitis. Diabetic subjects developed periodontitis at a younger age than non-diabetes subjects. This will represent a significant impact on life time dental service provision for subjects affected at a young age. The relationship between HbA1c and severe periodontitis is not a simple one. It is possible that unknown factors confound the relationship between glycaemic control and periodontitis. There was no relationship between duration of diabetes and periodontitis when age was controlled for. Chapter four presents the results of a small study investigating biomarkers of bone turnover in patients with and without T1DM and in patients with and without periodontitis. Patients with T1DM had higher levels of osteoprotegerin an osteoprotective molecule that normally leads to a reduced propensity for bone loss. T1DM patients were also shown to have reduced levels of biomarkers of bone formation (osteocalcin). It is possible that a reduced capacity for bone repair and regeneration may account for the increase levels of periodontitis seen in T1DM. Further prospective studies would be required to confirm this hypothesis. Chapter five investigated the level of caries and oral mucosal abnormalities in T1DM. There was little difference in caries indicators or in oral mucosal lesions between the groups. There was no difference in the bacterial microflora and in the level of resistance to antibiotics found in this cohort. T1DM patients, however, did have an increase in the symptoms of dry mouth, an increased density of candida colonisation and reduced salivary flow rates.Chapter six reports the data derived from the oral health questionnaire, including the Oral Health Impact Profile -14 (OHIP-14) and the Audit of Diabetes Dependent Quality of Life (ADDQOL©). Patients with T1DM, despite having increased levels of periodontal disease, reduced salivary flow rates and increased symptoms of xerostomia did not have higher OHIP scores by any measure. The reasons for this apparently negligible impact of oral disease or oral health related quality of life are discussed. The OHIP-14 was shown to have construct validity in this population although the correlations were relatively weak and the differences were small. It is possible that patients with T1DM do not consider the impact of their oral health to be a significant problem in light of their other on-going medical issues. This finding requires further in-depth investigation of the psychology behind this apparent reduced impact. This is the first study of its kind to examine the oral and dental health of non-smoking type 1 diabetic patients. The conclusions from the clinical data support the view that patients with T1DM should be targeted with oral and dental health advice. Encouragingly the prevalence of periodontitis was lower in well controlled diabetic subjects suggesting that the effect of T1DM on the oral cavity can be ameliorated by good glycaemic control even though logistic regression analysis did not show a linear relationship. It is important that health rofessionals work together in order to prevent and manage the oral complications of T1DM in the same way that there are preventive and screening programmes for other diabetic complications. The pathogenesis behind the increased prevalence and severity of periodontal disease in T1DM requires further study.

Item Type: Thesis (PhD)
Qualification Level: Doctoral
Keywords: Type 1 diabetes mellitus, periodontitis, oral disease, dental caries, xerostomia, oral candidiasis, oral health related quality of life, diabetes specific quality of life measures, Bone biomarkers, osteoprotegerin, osteocalcin, RANKL, ICTP,
Subjects: R Medicine > R Medicine (General)
R Medicine > RK Dentistry
Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Medicine > Dental School
Supervisor's Name: Hodge, Dr. Penny J.
Date of Award: 2011
Depositing User: Dr Douglas Paul Robertson
Unique ID: glathesis:2011-3009
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 14 Nov 2011
Last Modified: 10 Dec 2012 14:02
URI: http://theses.gla.ac.uk/id/eprint/3009

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