| Abstract|| |
BACKGROUND: Diabetes mellitus is considered as a risk factor for the initiation and progression of periodontal disease. The diabetic patients often exhibit decreased immune response and increased susceptibility to infection. In the present study, a quantitative estimation of the gingival tissue immunoglobulin concentrations in diabetic and non diabetic subjects with periodontitis was assessed and compared with that of clinically healthy gingiva. METHOD: 40 gingival tissue samples obtained from 20 diabetic (Type 2) and 20 non-diabetic subjects were subjected to quantitative estimation of immunoglobulins G, A, and M. The data thus obtained were compared to the level of immunoglobulin found in clinically healthy gingiva. RESULTS: The IgG and IgA level in the tissues of both diabetic and non-diabetic subjects with periodontitis were found to be significantly higher than that of healthy subjects. The diabetic group also showed a significantly higher IgG and IgA levels compared to the non-diabetic group with periodontitis. CONCLUSION: These findings support the concept that the humoral immune response plays an important role in the pathogenesis of periodontal disease in diabetics. The significantly higher levels of immunoglobulin in the gingival tissues might be a protective mechanism against the increased bacterial challenge in diabetic subjects.
Keywords: Immunoglobulins, diabetes mellitus, periodomitis, risk factors
|How to cite this article:|
Anil S. Immunoglobulin concentration in gingival tissue of type 2 diabetic patients with periodontitis. Indian J Dent Res 2006;17:151-4
|How to cite this URL:|
Anil S. Immunoglobulin concentration in gingival tissue of type 2 diabetic patients with periodontitis. Indian J Dent Res [serial online] 2006 [cited 2020 Jul 2];17:151-4. Available from: http://www.ijdr.in/text.asp?2006/17/4/151/29872
| Introduction|| |
Diabetes mellitus (DM) is a multi-factorial group of disorders associated with an abnormality in glucose metabolism. It is characterized by metabolic abnormalities and long term complications involving the eyes, kidneys, nerves, vasculature, and periodontium . The association between diabetes and periodontal disease has been well documented ,. Epidemiological studies found periodontal attachment loss to be more prevalent in subjects with either IDDM or NIDDM than in non-diabetic subjects . It has been assumed that this association exists because, the diabetic patients have a compromised ability to respond to infectious challenges, which predisposes the patient to bacterial infections like periodontal diseases. Clinicians have long assumed that individuals with diabetes mellitus have an increased risk for periodontitis ,,. Several cross sectional studies have shown diabetes as a risk factor for increased incidence of periodontal diseases. In a two-year-old follow up study, Taylor et al  has established that diabetes mellitus is a significant risk factor for more severe alveolar bone loss progression as well as for increased incidence of bone loss. Extensive reviews of the relationship of DM and periodontal disease have concluded that diabetic patients are at risk to periodontal diseases. Loe  acknowledged periodontal disease as the '6th' complication of diabetes. A review by Rees  concluded that there is a direct relationship between diabetes mellitus and periodontal disease.
Although the factors promoting periodontal disease in individuals with diabetes mellitus have not been satisfactorily explained, numerous hypotheses have been proposed to explain the relationship. Ficara et al  suggested that the elevated blood glucose in GCF of poorly controlled diabetics might favor the growth of certain pathogenic microorganisms in periodontal pockets. Decreased ingestion and killing ofbacteria by neutrophils in poorly controlled patients  have also been reported earlier. Diabetic microangiopathies, which are related to poor control of diabetes may also add to the impaired host response in the sulcular area.
Immune mechanism has been shown to play an important role in the initiation andprogression ofperiodontal disease. Cell mediated immunity is reported to play a protective or aggressive role in the pathogenesis of periodontal disease. Altered immune function in diabetic patients with periodontitis have been cited in many immunological studies ,,,,,. The previous studies from our centre showed a significantly elevated serum immunoglobulins and complement factors in diabetic patients with periodontitis ,. Fontana et al  also concluded that a systemic factor might be responsible for promoting the local pathological alterations, which produce gingivitis and periodontitis in diabetes patients. Little research has been carved out to estimate the levels of inununoglobulin in the gingival tissues of diabetic patients with periodontitis. Hence the present study is undertaken to estimate the levels of immunoglobulin in the gingival tissues of diabetic (Type 2) and non-diabetic patients with periodontitis.
| Materialsand methods|| |
Diabetes patients were recruited from the Diabetic Research Center of the Medical College Hospital, Kerala, India. The non-diabetic group of patients were selected from the outpatients attending the dental outpatient unit. 20 diabetic and 20 non-diabetic patients (age group 35-55) with chronic periodontitis were included in the study. Patients selected were having at least 20 permanent teeth in mouth, without caries, with no history of infections of the salivary glands, upper respiratory tract infections, allergy or autoimmune disorders. Patients with controlled diabetes mellitus (type2) with history of 5-7 years were considered. The plasma glucose and glycated hemoglobulin levels (HbAlc) helped to assess the metabolic control.
Probing pocket depth and clinical attachment loss assessed the periodontal conditions of the diabetic and non-diabetic patients with periodontitis. The mean probing depth of ≥ 4 mm and clinical attachment loss of ≥ 3 mm in atleast 40 percent of teeth present were considered to be included in the periodontitis group. The control subjects selected had a healthy gingiva with no clinical attachment loss and a probing pocket depth less than or equal to 3mm.
The procedure was explained to the patient and a written consent was taken. Gingival biopsy was performed under aseptic conditions. In some of the cases, the tissue was collected during the periodontal surgical treatment. Immediately following the surgical removal, the tissue was rinsed in three changes of saline to remove surface blood, was frozen within 30 min, and was stored at-70°C. Prior to homogenization, the gingiva was thawed, diced into 1 to 2 mm cube, and thoroughly homogenized over ice in a 19 x 150 mm Pyrex tissue grinder. Sufficient distilled water was added to the tissue to aid homogenization.
The specimens were stored at -20°C till immunoglobulin estimations were carved out. Gingival tissues obtained from 20 healthy individuals were used for comparison. The healthy gingival tissue was obtained from patients undergoing crown-lengthening procedures and from the patients undergoing surgical correction of jaw and maxillofacial deformities at the maxillofacial surgery unit. The healthy tissues obtained were also processed and stored forimmunoglobulinestimations.
IgG, IgA, and IgM were quantitatively determined with the help of single radial immunodiffusion technique . 20 pl specimens were assayed using low-level immunodiffusion plates ,. Low concentration immmhodiffusion plates (LC-Partigen® Immunodiffusion Plates, Behringwerke, Marburg, Germany) were used for the estimation of immunoglobulin in tissue homogenate.
The statistical analysis was done using Tukey-Kramer Multiple Comparison test using Instat® (Graph Pad Software, Inc.San Diego, USA) programme. P values of <0.05 were considered statistically significant.
| Results|| |
The mean concentrations of IgG, IgA and IgM are depicted in [Table - 1] and [Figure - 1]. The IgG and IgAlevels were found to be significantly higher in tissues obtained from both the periodontitis group and diabetes group as compared to the healthy controls. Tukey-Kramer multiple comparisons test showed significantly higher levels of IgG and IgA in tissues obtained from the diabetic subjects with periodontitis when compared to non-diabetics with periodontitis. When compared to a 25% detection rate for normal gingival, the incidence of IgM detection was higher in diabetic (55 %) as well as in periodontitis group (45%).
| Discussion|| |
The association between periodontal disease and diabetes has been extensively explored in several studies over the years, and it is generally accepted that periodontal disease is more prevalent and severe in persons with diabetes than in non-diabetic persons ,. Although these studies have shown the association between periodontal disease and diabetes, the underlying mechanism has yet to be defined. Attention has been focused to monitor host immunological response of diabetic individuals. Studies on the polymorphonuclear leukocytes function in Type 2 diabetic patients with periodontal disease have shown defects in the chemotaxis and phagocytosis functions. Decreased chemotaxis, adherences, phagocytosis, and intracellular killing have been reported earlier and are regarded as the result of bacterial infection . Diabetic patients with periodomitis have been shown to have depressed chemotaxis of peripheral blood leukocytes .
A significantly high serum immunoglobulins and complements have been reported in Type II diabetes patients with periodontitis ,,. Fontana et al in their studies also observed similar findings . In the present study, the concentrations of the IgG and IgA in gingival tissues of diabetic and non-diabetic patients were found to be significantly high, when compared to the healthy subjects. The tissue alterations caused by diabetes may create an environment that is less resistant to the invasion ofmicroorganisms .
The concentration of immunoglobulins are in agreement with the results reported by Byers et al  who reported higher levels of IgA and IgG in inflamed human gingiva. Gross et al  demonstrated IgM in clinically normal gingival specimens. In the present study, IgM was detected in 5 out of 20 specimens of healthy gingival tissues. The tissues from the periodontitis cases showed the presence of up to 45 to 55 percent, which agrees with previous reports ,,. The increased concentrations of IgG and IgA in inflamed gingiva, and the occasional fording oflgM tend to be in agreement with earlier reports . However, Thonard et al  failed to detectIgG in inflamed gingiva. The increase inthe level of IgG and IgAinthe gingival tissue possibly occurred due to prolonged activity of bacterial antigens stimulating local production of IgG and IgA in the gingival tissue. It is possible that increase in concentration of immunoglobulin in gingival tissues ofdiabetic group may be representing an enhanced response to diabetic state in periodontitis. Possible protective effects however maybe offset by a dysfunction of polymorphonuclear leuncocyte manifested by a reduction in phagocytosis and a diminished response to chemotactic stimuli in diabetic group as reported by Bissada et al . The observations of the present study farther explain the possible relation associated with increased rate of tissue destruction in diabetic patients with periodontitis. Further studies are mandatory to substantiate these observations.
| Acknowledgments|| |
The technical guidance of the Dr. T. Vilayakumar and Dr. P. Remani, Immunology Division of the Regional Cancer Centre, Kerala is gratefully acknowledged.
| References|| |
|1.||Sherwin RS, Anderson RM, Buse JB, Chin MH, Eddy D, Fradkin J, Ganiats TG, Ginsberg HN, Kahn R, Nwankwo R, Rewers M, Schlessinger L, Stern M, Vmicor F, Zimmm B: Prevention or delay of type 2 diabetes, Diabetes Care, 27 Supp11:S47-54, 2004. |
|2.||Taylor GW: Exploring interrelationships between diabetes and periodontal disease in African Americans, Compend Contin Educ Dent, 22(3 Spec No):42-48, 2001. |
|3.||Mealey B: Diabetes and periodontal diseases, J Periodonto1,70(8):935-949,1999. |
|4.||Cutler CW, Machen RL, Jotwani R, Iacopmo AM: Heightened gingival inflammation and attachment loss in type 2 diabetics with hyperlipidemia, JPeriodonto170(11):1313-1321,1999. |
|5.||Oliver RC, Tervonen T: Diabetes--a risk factor for periodontitis in adults? J Periodontol, 65(5 Suppl):530-538,1994. |
|6.||Emrich LJ, Shlossman M, Genco RJ: Periodontal disease in non-insulin-dependent diabetes mellitus, J Periodonto1,62(2):123-131,1991. |
|7.||Shlossman M, Knowler WC, Pettitt DJ, Genco RJ: Type 2 diabetes mellitus and periodontal disease, J Am DentAssoc,121(4):532-536,1990. |
|8.||Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M, Knowler WC, Pettitt DJ: Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus, J Periodontol, 67(10 Suppl):1085-1093, 1996. |
|9.||Loe H: Periodontal disease. The sixth complication of diabetes mellitus, Diabetes Care, 16(1):329-334, 1993. |
|10.||Rees TD: The diabetic dental patient, Dent Clin NorthAm, 38(3):447-463,1994. |
|11.||Ficara AJ, Levin MP, Grower MY, Kramer GD: A comparison of the glucose and protein content of gingival fluid from diabetics and nondiabetics, JPeriodontalRes,10(3):171-175,1975. |
|12.||Repine JE, Clawson CC, Goetz FC: Bactericidal function of neutrophils from patients with acute bacterial infections and from diabetics, J Infect Dis, 142(6):869-875,1980. |
|13.||Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study, Brit Med J, 321(7258):405-412,2000. |
|14.||Tenovuo J, Lehtonen OP, Viikari J, Larjava H, Vilja P, Tuohimaa P: Immunoglobulins and innate antimicrobial factors in whole saliva ofpatients with insulin-dependent diabetes mellitus, J Dent Res, 65(1):62-66,1986. |
|15.||Anil S, Remani P, Ankathil R, Vijayakumar T: Circulating immune complexes in diabetic patients with periodontitis, Ann Dent, 49(2):3-5, 45,1990. |
|16.||Anil S, Remani P, Beena VT, Nair RG, Vjayakumar T: Immunoglobulins in the saliva of diabetic patients with periodontitis, Ann Dent, 54(1-2):30-33,1995. |
|17.||Anil S, Remani P, Vijayakumar T, Hari S: Cellmediated and Immoral immune response in diabetic patients with periodontitis, Oral Surg Oral Med Oral Pathol, 70(1):44-48,1990. |
|18.||Anil S, Remani P, Vjayakumar T, Joseph PA: Total hemolytic complement (CH50) and its fractions (C3 and C4) in the sera of diabetic patients with periodontitis, J Periodontol, 61(1):27-29,1990. |
|19.||Fontana G, LapollaA, Sanzari M, Piva E, Mussap M, De Toni S, Plebani M, Fusetti F, Fedele D: An immunological evaluation oftype II diabetic patients with periodontal disease, J Diabetes Complications, 13(1):23-30,1999. |
|20.||Mancini G, Carbonara AO, Heremans JF: Immunochentical quantitation of antigens by single radial immunodiffusion, Immunochemistry, 2(3):235-254,1965. |
|21.||Grass A, Setterstrom JA, D'Alessandro SM, Van Swol RL: Immunoglobulins in periodontal tissues. I. Concentrations of immunoglobulins in normal and inflamed gingiva, J Periodontol 50(11):581-585, 1979. |
|22.||Van Swol RL, Gross A, Setterstrom JA, D'Alessandro SM: Immunoglobulins in periodontal tissues. II. Concentrations of immunoglobulins in granulation tissue from pockets ofperiodontosis and periodontitis patients, J Periodontol, 51(1):20-24, 1980. |
|23.||Cutler CW, Eke P, Arnold RR, Van Dyke TE: Defective neutrophil function in an insulindependent diabetes mellitus patients. A case report, J Periodontol, 62(6):394-401,1991. |
|24.||Naghibi M, Smith RP, BaItchAL, Gates SA, Wu DH, Hammer MC, Michelsen PB: The effect of diabetes mellitus on chemotactic and bactericidal activity of human polymorphonuclear leukocytes, Diabetes Res ClinPract, 4(1):27-35,1987. |
|25.||Grant Theule DA: Periodontal disease, diabetes, and immune response: a review of current concepts, J West SocPeriodonto144(3):69-77,1996. |
|26.||Byers CW, Toto PD, Gargiulo AW: Levels of immunoglobulins IgG, IgA, and IgM in the human inflamed gingiva, J Periodontol, 46(7):387-390, 1975. |
|27.||Brandtzaeg P: Immunology of inflammatory periodontal lesions, Int Dent J, 23(3):438-454,1973. |
|28.||Thonard JC: The microbiology of periodontal disease, Ala J Mod Sci, 5(3):302-310,1968. |
|29.||Bissada NF, Manouchehr-Pour M, Haddow M, Spagouolo PJ: Neutrophil functional activity in juvenile and adult onset diabetic patients with mild and severe periodontitis, J Periodontal Res, 17(5): 500-502,1982. |
Dept. of Periodontics, College of Dentistry, King Saud University, Post Box: 60169, Riyadh 11545
Source of Support: None, Conflict of Interest: None
[Figure - 1]
[Table - 1]