KEMAS 12 (1) (2016) 18-24

Jurnal Kesehatan Masyarakat

http://journal.unnes.ac.id/nju/index.php/kemas

THE INCREASE OF PERIODONTAL TISSUE IN TYPE 2 DIABETES MELLITUS

PATIENTS BASED ON INDEX CPITN

Budiman, Ani Fitriana

Study Program of Public Health Stikes Jenderal A. Yani Cimahi, Indonesia

Article Info Abstract

Article History: The prevalence of periodontal disease in Indonesia for all age groups has reached 96.58%.
Submited Periodontal disease has been identified as a consequence of diabetes mellitus (DM). The
Accepted purpose of this study is to determine the differences of periodontal tissues in type 2 dia-
Published July 2016
betes and non-diabetic patients based on CPITN index (Community periodontal index
Keywords: of Treatment index). This study employed case control design. The population of the
Periodontal; Type 2 Diabetes study consisted of 3.544 visits in the Internal Disease Polyclinic of RSUD Cimahi Cibabat
Mellitus; CPITN Index in January 2015. The samples for case group were 50 people (diabetes mellitus type 2)
and control group were 50 people (non-DM). The sampling technique used accidental
DOI sampling. The study was conducted in 2015 by conducting measurement of periodontal
http://dx.doi.org/10.15294/ pocket depth using CPITN index. The analysis of data was carried out with independent
kemas.v12i1.5954 T test. The results show that the average pocket depth based on CPITN index in the case
group of type 2 DM (4.26) is greater than control group of patients without DM (3.14).
There is different condition on the periodontal tissue in the group of type 2 diabetes
(value-p = 0.002 <0.05). The awareness in increasing the oral health protection is done
by providing consultation related to blood glucose.

Introduction The prevalence of diabetes in Indonesia

Based on the data from the International in 2013 is 2.1%. This figure is higher than 2007
Diabetes Federation (2003), it is estimated that (1.1%). A total of 31 provinces (93.9%) show
in 2003, there are approximately 194 million that the increase of diabetes mellitus prevalence
people who have diabetes mellitus worldwide. is significant. The highest prevalence of
This has reached 5.1% of the world population. diabetes at age ≥ 15 years according to the
This number is expected to increase to 333 doctor’s diagnosis/symptoms Riskesdas in
million, or 6.3% of the world’s population by 2013 is in Central Sulawesi (3.7%), followed
2025. Global status report on NCDs World by North Sulawesi (3.6%) and South Sulawesi
Health Organization (WHO) in 2010 reported (3.4%). The lowest prevalence is in Lampung
that 60% of the death cause of all ages in the (0.8%), then followed by Bengkulu and West
world is because of Non-Transmitted Disease. Kalimantan (1.0%). The province with the
Diabetes mellitus (DM) is ranked the sixth largest prevalence increase is in South Sulawesi
leading cause of death. About 1.3 million people (0.8%) in 2007 to 3.4% in 2013. The highest
died from diabetes and 4 percent die before the decrease of prevalence is in West Papua, namely
age of 70 years. In 2030 the estimated diabetes 1.4% in 2007 to 1.2% in 2013 (Badan Penelitian
mellitus ranks 7th of leading cause of death in dan Pengembangan Kesehatan, 2013).
the world. In Indonesia, it is expected in 2030, The report from Household Health
there will be 21.3 million people with diabetes Survey of Ministry of Health in 2001 stated that
mellitus (diabetes). among the complained and non-complained

Correspondece Address: P-ISSN 1858-1196
Jl. Terusan Jendral Sudirman, Cimahi, 40533, Indonesia E-ISSN 2355-3596
Email : budiman_1974@yahoo.com
 KEMAS 12 (1) (2016) 18-24

illness, the prevalence of oral and dental mellitus (1.77) and this difference is statistically
diseases were the highest, covering 60% of significant (p <0.05). Periodontitis is a factor
the population. The results of the survey from for the development of type 2 diabetes, and vice
dental health data in 2001 of periodontal versa, patients with type 2 diabetes mellitus are
status in the age group of 25-34 years showed more prone to suffer periodontitis and more
the prevalence of people with calculus 47.40% severe than non-diabetic patients (Struch, F.,
and periodontitis 8.40%. The periodontitis 2008)
prevalence was very low at 9% (Kementrian The preliminary study on 10 patients
Kesehatan RI, 2002). with type 2 diabetes mellitus was carried out by
There are still many people who do not the writer on March 31, 2015 in the polyclinic
know that diabetes mellitus is closely associated of internal disease of RSUD Cibabat Cimahi.
with periodontal disease, which is a chronic The test done on periodontal tissues based on
inflammatory disease in the tissue supporting the index CPITN shows that there is 1 person
the teeth. Periodontitis has been identified as who has score 2 (no tartar on sub gingival), 5
the sixth complication of diabetes. Some studies people who have score 3 (shallow pocket), 4
suggest that diabetes becomes the risk factor people with score 4 (deep pocket). The results
of prevalence, severity of gingivitis (gingival of interviews conducted on 10 people with
inflammation) and periodontitis (inflammation diabetes mellitus in the maintenance of oral
of the periodontal tissues). health show that the patients do not know how
In general, almost 85% prevalence of to maintain their oral health well and correctly
diabetes mellitus is type 2diabetes mellitus. such as right brushing techniques and timing.
In type 2 diabetes, the patients are suffered They rarely and never even check or control to
no damage to the insulin-producing cells. the dental clinic for treatment such as fillings,
However, those cells cannot function properly. scaling and consequently many patients
Type 2 diabetes mellitus is a very significant complain that their teeth loosing and having
concern to public health. Periodontal disease cavities.
has been known traditionally as a consequence Based on this, the writer would like
of diabetes. Epidemiological studies have shown to further examine the condition of the
that diabetes increases the risk of alveolar bone periodontal tissue in patients with type 2
loss and attachment loss in periodontal tissues diabetes mellitus as compared to non-diabetic
three times greater as compared to non-diabetic patients in the clinic CPITN based on index of
patients (Mealey.B., 2008). disease in hospitals Cibabat 2015.
Periodontal disease is a disease that
affects many people in various countries which Method
is a complication of diabetes mellitus. Therefore, This study is an analytic survey with a
to determine the prevalence and severity of the design that used a case control study. The reason
disease, it can be followed by more intensive why the writer used a case control design for
efforts from WHO in combating the disease is to this study was to identify a group of subjects
develop CPITN index (Community periodontal with effects (diabetes mellitus patients) as a case
index of Treatment index) to describe the level group and a group of subjects without effect as
of periodontal tissue condition also illustrates the control (non-diabetes mellitus) as a control
the type and maintenance needs (Megananda, group and then retrospectively investigated the
2009). presence or absence of risk factors.
The study from Hindriyana (2011) on The population in this study was all
a sample of 45 people with type 2 diabetes patients who visited the clinic of the disease in
mellitus patients and 45 people without diabetes hospitals Cibabat in January 2015 amounted to
mellitus, there are differences between the mean 3544 visits. Calculation of the samples using
index of CPITN in patients with type 2 diabetes the formula of Lemeshow (1997) with a large
mellitus and patients without diabetes mellitus. sample of cases acquired as many as 50 people
In patients with type 2 diabetes (2.11), it is and used comparisons between cases and
higher as compared to patients without diabetes controls 1: 1. The total samples obtained were

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Budiman, Ani Fitriana / The Increase of Periodontal Tissue in Type 2 Diabetes Mellitus

100 votes (consisting of 50 people as case group

and 50 people as control group). The sampling Referring to Table 1, the results of the
technique used was accidental sampling. study in patients with type 2 diabetes mellitus
The writer selected group of cases who were after measurement index score is almost
registered and identified in RSUD Cibabat evenly distributed among scores of 0, 2, 3,
which were incidentally encountered during a and 4. It shows that score 3 indicates CPITN
visit to the internal poly, including in selecting index in patients with type 2 diabetes with the
the control group. highest proportion of 30%. For frequencies
Data collection was conducted through of periodontal conditions based on the
the examination of the patient with type 2 periodontal pocket in groups of patients with
diabetes mellitus and patients without diabetes type 2 diabetes are listed in Table 2.
mellitus based on CPITN index using WHO According to the table 2, the group of
Periodontal Examining Probes for measuring patients with type 2 diabetes has the average
the teeth of the upper jaw and teeth of the lower depth of periodontal pockets of 4.26 mm. It
jaw is divided into 6 sextants, with teeth index 71, shows that that the depth level obtained is at
61, 11, 21, 26, 27, 37, 36, 31, 41, 46, 47, to obtain least 2 mm and a maximum of 8 mm. Onwards,
data on the condition of the periodontal tissues. we can see the score index of CPITN and
Secondary data from the polyclinic of internal periodontal pocket depth in the group that do
disease in RSUD Cibabat was in the form of not suffer from diabetes type 2 as shown in the
data from the medical records of patients with following table.
type 2 diabetes mellitus and without diabetes
mellitus. The collected data was then analyzed Table 2. Frequency Distribution of Periodontal
using univariate and bivariate analysis with Tissue Conditions Based on Periodontal Pocket
mean difference test namely independent t test Depth in Patients with Type 2 Diabetes Mellitus
and significance level of 95% or the value of α Mean Min-
Variables Group S.D 95% CI
= 0.05 (5%). Median Max
Pocket Depth DM TIPE 2 4,26 1,915 2-8 3,72-4,80
Results and Discussion Periodontal 4,5
The primary data source in 2015
This research was conducted in the clinic
of internal disease in RSUD Cibabat, with 100
respondents consisting of 50 research subjects Table 3. Frequency Distribution of Periodontal
who were diagnosed with type 2 diabetes tissue Conditions of Non Patients with Diabetes
mellitus and met the inclusion criteria were Mellitus Based on CPITN Index Score
selected as the case group and 50 subjects Observed Group
were not diagnosed with diabetes mellitus as a CPITN Index Patients without DM
control group with research as follows. Total Percentage
Score 0 8 16%
Table 1. Frequency Distribution of Periodontal Score 1 0 0%
Tissue Conditions of Patients with Type 2
Score 2 23 46%
Diabetes Mellitus Based on Index Score CPITN
Score 3 14 28%
Observed Groups Patients Score 4 5 10%
CPITN Index with type 2 DM
Total 50 100%
Total Percentage The primary data source in 2015
Score 0 11 22%
Score 1 0 0% Referring to Table 3, it shows that in
Score 2 13 26% patients with non-DM group CTPM index
Score 3 15 30% scores varied. The highest proportion turned
Score 4 11 22% out to CPITN index score of 2 is 23 respondents
Total 50 100% (46%) while the lowest is in the score of 4 which
The primary data source in 2015 has 5 respondents (10%). Periodontal pocket

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 KEMAS 12 (1) (2016) 18-24

depth in patients with non-DM group is listed Until now, there are many people who
in the following table 3. do not know that diabetes mellitus is closely
Investigating table 4, the average associated with periodontal disease. Diabetes
frequency of the periodontal tissue condition of mellitus is generally associated with “offspring”
the in patients with Non DM is 3.14 mm with factor (Ridwan, 2015). This is not solely heredity,
the maximum of 6mm. To know the average but periodontitis has been identified as the sixth
depth of periodontal pockets based on index in complication of diabetes mellitus (Indrasari,
patients with type 2 diabetes mellitus and non- 2013). There are some things that happen in
DM shown, the following table is presented: DM patients which worsen periodontal tissue
health including: glucose content in the liquid
Table 4. Frequency Distribution of Periodontal gums and blood in patients with DM can change
Tissue Conditions Based on Periodontal Pocket the environment of microbes into qualitative
Depth in patients without Diabetes Mellitus bacteria that affect the severity of periodontal
Variables
Mean
Groups S.D
Min-
95% CI
disease.
Median Max Periodontal tissue is closely related to
Pocket Depth Non DM 3,14 1,616 0-6 2,68-3,60
Periodontal 3,00 food impaction or retention i.e. food leftovers
The primary data source in 2015 in the oral cavity which are usually tucked
between the teeth, or to pile on the basin in
Table 5 shows that the average depth the neck of the teeth near the gingiva. Food
of periodontal pockets in type 2 DM group impaction occurs due to food habits performed
is higher (4,26mm) as compared to non-DM by people with type 2 diabetes mellitus. Puspita
group (3,14mm). The result of statistical tests (2011) states that eating pattern habit influences
at alpha 5% shows that Ho is refused. This people with diabetes. Rikawarastuti’s study
means that there are significant differences (2015) finds that the severity of the diabetic
in periodontal pocket depth among type 2 group is 3.5 times higher than the group of
diabetes patients with non-DM. people who do not have DM (value OR = 3.5)
Periodontitis is an inflammation of the and shows no significant relationship between
gum tissues supporting the teeth bones that the severity of periodontal tissue with DM (p
forms a pocket where the tooth is located and = 0.002).
periodontal ligament. Diabetes Meilitus (DM) The average depth of periodontal
is a metabolic disease disorders in which the pockets in respondents with diabetes mellitus
body’s hormone insulin does not work as it type 2 is 4.26 mm, median 4.5 mm (95% CI:
should. DM is a systemic disease which is one 3.72 to 4.80) with a standard deviation of 1.915
of the risk factors for periodontitis. The highest mm with a low of periodontal pocket depth
score of frequency of periodontal tissue by of 2 mm and the highest periodontal pocket
CPITN index scores in patients with type 2 depth of 8 mm. Periodontal status of diabetic
diabetes mellitus is 3 (pocket with a depth of 4 patients in Polyclinic Endocrine Hospital Prof.
or 5 mm gingival edge is located on the probe DR. R. D. Kandou Manado shows that none of
black). The result of Hindriyana’s study (2011) the diabetic patients has periodontal status of
shows that in CPITN distribution of 45 samples good or normal, there are 16 patients (43.2%)
with type 2 diabetes, there are 4 people who have with medium status and 21 patients (56.8%)
score 4. The average index CPITN in patients with poor periodontal status. Patients with
with type 2 diabetes mellitus is 2.11. A study type 2 diabetes mellitus are more severe if they
conducted by Renata, Pajauta, Gediminas, et al have poor periodontal status as compared with
in Lithuania states that, out of 126 samples, 27 healthy people. Diabetes is associated with
are diagnosed with periodontitis (Index CPITN excessive inflammation response of gingivi
score of 4), 38 (Index CPITN score of 3) and toward plaque.
31 (Index CPITN score of 2), gingivitis is found Patients with diabetes who have good
in 27 subjects (CPITN Index score of 1). Only control over their blood sugar levels (good
2.4% of studied patients with diabetes have glycemic / metabolic control) can prevent or
healthy periodontal tissues. delay and slow the progression of diabetic-

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Budiman, Ani Fitriana / The Increase of Periodontal Tissue in Type 2 Diabetes Mellitus

related complications, particularly retinopathy, patient. If the sequence of these events last for a
nephropathy, and neuropathy. Similarly, it long time, chronic infection can lead to severe
applies to delay or to slow the progression of periodontal damage and loss of teeth. Recent
periodontal disease. However, for people with research shows that there may be a period of
diabetes who have poor glycemic control (high active bone resorption followed by a period of
blood sugar levels), the risk of infection becomes inactivity where no periodontal pockets but do
much greater. For example, it is estimated that not cause a further attachment loss.
the uncontrolled diabetes patients are at risk Patients without diabetes mellitus have
of 2 to 4 times higher to develop periodontal lower level of periodontal disease conditions
infection than non-diabetic people. Then the as compared to patients with diabetes mellitus.
diabetic patient should be able to control the rate However, it does not rule out the possibility,
of blood glucose manner dietary adjustments based on the observation of patients, that
(Arimandaliza, 2011). A bad dietary pattern diabetes mellitus is also a risk of periodontitis.
will cause trouble in the process of food in the The local risk factors is imperfect tooth
mouth that can leave plaque on teeth or pockets anatomy (crowding and spacing between the
in periodontal tissues. teeth), the patient is wearing dentures, poor
Periodontal tissue based score index denture will result in severe damage to the
CPITN in patients with diabetes mellitus structure of periodontal tissue, the formation
who has the highest score is a score of 2 (the of calculus (tartar teeth), patients are not
calculus, but all parts of the black probe are still informed about tooth brushing technique and
visible, there are pockets with a depth of more brushing frequency. Some patients are also
than 3 mm) as many as 23 people (46%). The smokers and smoking is an important factor in
average index of CPITN in patients with type 2 the development of periodontitis.
diabetes mellitus is higher compared to patients Synthesis and secretion of cytokines
without diabetes mellitus (1.77) and this as a result of infection from periodontitis
difference is statistically significant (p <0.05). can intensify the synthesis and secretion of
The obtained results show that the average cytokines. The association of periodontitis with
depth of periodontal pockets based on CPITN DM takes place in two directions. Periodontal
index in patients with diabetes is higher than disease which is a chronic inflammatory form
patients without diabetes mellitus. It concludes can aggravate diabetes mellitus status towards
that patients with type 2 diabetes have more more severe complications. The results show
severe periodontal tissue damage than patients that diabetes complications in diabetes mellitus
without diabetes mellitus. In accordance with type 1 and type 2 are more severe in diabetic
the score CPITN index, people with diabetes patients with severe periodontal disease as
mellitus require greater periodontal treatment compared to diabetic patients who suffer
than patients without diabetes mellitus. only mild to moderate periodontal disease.
Periodontitis starts with gingivitis and Severe chronic periodontitis in DM patients
if the possibility of an inflammatory process, is suspected to be the cause for the increase in
then most patients but not all patients, will concentration of glycated hemoglobin. Infection
gradually enter the deeper inflammatory from periodontitis in addition to increasing the
periodontal tissue. Together with inflammatory production of cytokines could be expected to
process, there will be the potential to stimulate also increase insulin resistance, which in turn
periodontal tissue resorption and formation worsens glycemic control in diabetics who also
of periodontal pockets. With the formation suffer from periodontitis in his mouth.
of pockets, inflammatory periodontal disease Diabetes can increase the risk of damage
becomes self-perpetuating principal of to the periodontal tissue that continues over
etiological factors, namely plaques, which at this time. A longitudinal study shows that in patients
time, is formed inside anaerobic environment with type 2 diabetes, the risk is increased four
pocket which encourages the growth of times in alveolar bone loss in adults compared
pathological periodontal organisms and is to adults who do not have diabetes. Such as
more difficult to access for discarded by the gingivitis, periodontitis development risk is

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 KEMAS 12 (1) (2016) 18-24

greater in patients with diabetes who have mouth easily experience great alveolar bone
poor glycemic control as compared to patients loss in periodontal infections. Adjustments
with well-controlled diabetes. Low glycemic supplements can prevent periodontitis.
control in patients with diabetes also has been Supplementation combination of ATRA and
associated with an increased risk of progressive Zn gives high collagen synthesis closest to the
loss of periodontal tissue attachment and state of health (Hanafi, P., 2015).
alveolar bone (Mealey, 2006). Diabetic patients The prevention which needs to be done
with periodontitis also have elevated levels is by examination and routine care to the dental
of C-reactive protein on periodontal health health team, in order to determine ways to
status (Yekti, N., 2014). Even, these patients maintain healthy teeth and mouth and dental
will experience a decrease in alveolar bone health team must also provide the motivation
and thinning of the mandible cortical bone to apply the advice and guidance that has
(Epsilawati, 2012). been given. This starts with conducting oral
Patients with type 2 diabetes mellitus health examinations to dental clinic at least
who go to RSUD Cibabat have more severe six months, regular maintenance for scaling
periodontal disease than patients without and brushing teeth at home regularly and
diabetes mellitus. This is caused by high doing right techniques of brushing. Regular
glycemic control in patients with diabetes checkup to internal disease clinic is important
with periodontal disorders which are always to control blood sugar levels, because in order
accompanied by a local function and local to maintain dental and oral surgical procedures
irritation factor. Principles of treatment of or risk, such as extraction of teeth a patient’s
periodontitis in diabetic patients are similar blood sugar levels should be controlled. Blood
to that of patients without diabetes mellitus glucose levels have a significant relationship
due to all high-risk patients who already have with the incidence of dental caries in patients
periodontal disease. Great efforts should be with type 2 diabetes mellitus (Budiman, 2015).
directed to prevent periodontitis patients at Maintaining the health of the whole body
risk of diabetes. Diabetes patients with poor is very important so that the disease can be
metabolic control should be seen more often, controlled and the control will be effective
especially if periodontal disease already exists. when the patient is completely aware and know
Patients with uncontrolled diabetes, who have the purpose of such action.
good oral hygiene and periodontal treatment,
have the same risk of severe periodontitis Conclusion
as non-diabetics. Diabetes is a long-term The condition of the periodontal tissues
impact on micro vascular complications of patients with type 2diabetes mellitus who
leading to ischemia and malnutrition on the have the highest score is 3 (pocket with a depth
network (Budiman, 2015). Periodontitis can of 4 or 5 mm, and the edge of the gingival are
cause excessive inflammation with increased on the probe black) whereas in patients without
TNF-α, IL-6.IL-1 enters the circulatory system diabetes mellitus, the highest score is 2 with
(Engebretson, 2007). depth more than 3 mm. The average depth of
During the treatment, health periodontal pockets in patients with diabetes
professionals need to explain to patients mellitus respondents is 3.14 mm, and there are
about the constraints that exist in the case of significant differences between the periodontal
controlling blood sugar levels and periodontal tissue conditions of type 2 diabetes mellitus.
disease, since patients must also participate
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