Diabetes mellitus is a non-communicable, chronic condition that presents a global health concern. Type 2 diabetes mellitus disease is manifested with hyperglycemia resulting from defective insulin action due to resistance by the cells, consequently leading to complications that cause reduced lifespan and quality of life. Diabetes mellitus type 2 is the prevalent form of diabetes, representing 85 % of all the cases, and its prevalence has drastically risen recently, becoming the twelve leading cause of mortality globally (Tandon et al., 2015). Long-term complications are triggered by the hyperglycemic condition in diabetic patients ranging from eye impairments, kidney problems, cardiomyopathy, lower limb amputation, stroke, and large vessel disease. Periodontal disease, a chronic oral disease featured by inflammation of tissues supporting and attaching teeth in the jaws, is strongly associated with diabetes mellitus disease. The condition eventually results in loss of teeth, bad breath, gum pocket formation, gum recession, bleeding gums, and swollen gums. The inflammatory host responses are responsible for the onset and progression of the disease despite mixed endogenous gram-negative bacteria infections initiating and maintaining the condition (Stanko et al., 2014). The severity and susceptibility of periodontal diseases are aggravated by diabetes mellitus since increased inflammation is associated with diabetic complications. Individuals with type 2 diabetes mellitus demonstrate high levels of circulating interleukin and tumor necrosis factor and elevated T helper 1 to T helper 2 ratios which are liked with microvascular complications (Graves et al., 2020).
Periodontal diseases include periodontitis and gingivitis, which manifest as inflammatory, microbially, and chronic induced disorders affecting the structure and functionality of the tooth. Gingivitis is locally gum inflammation and is reversible resulting from dental plaque accumulation in the surfaces of teeth, and the bacteria contained in the sticky biofilm is responsible for the initiation of and progression of subsequent diseases. The treatment of gingivitis is achieved by flossing and brushing, which results in plaque removal; however, the more serious periodontitis may result from localized inflammation (Molina et al., 2016). The inflammation progresses towards the bone supporting the tooth and the adjacent connective tissues, consequently causing bone resorption, periodontal pockets formation, and tissue destruction. A manual periodontal probe can assess the periodontal disease requires measuring gingivitis values and periodontitis assessment. In the final measurement of periodontitis, the number of teeth involved, the severity of the sites involved, tooth loss, and the attachment loss as indicated by the distance between the base of the pocket and the cementoenamel junction of the tooth bone loss are included. Periodontitis is classified into either severe, moderate, or mild, and after the periodontium is affected, the mechanical disruption of biofilm is necessary to facilitate the healing process in addition to antibiotics treatments. When the affected individuals are more susceptible, the disease spreads to the periodontium towards the pocket between the tooth and gum, where changes by Gram-negative bacteria ensue, leading to extensive inflammatory responses, which result in bone and connective tissue breakdown. Systemic and local inflammatory immune responses are activated in the host after further destruction resulting in extensive systemic infections and playing a role in the pathogenesis of the associated systemic disease.
Progression and advancement of periodontal diseases are twice in diabetic individuals compared to non-diabetic individuals revealing a strong relationship with diabetes mellitus (Kim et al., 2020). In addition, poorly controlled diabetes mellitus increases the risks for the development of severe periodontal disease as well as gingival inflammation and more severe gingival bleeding compared to the non-diabetic Mellitus individuals. The link between periodontal disease and diabetes mellitus is bidirectional, which the former adversely affects glycemic control in diabetic individuals and elevates the risk of development of diabetic Mellitus complications (Tse, 2018). Surprisingly, uncontrolled diabetic Mellitus patients experience higher mortality rates compared to those with controlled or non-diabetic disease status. A study conducted by Hasan et al. (2021) demonstrated that diabetic-related clinical determinants contribute to the development of periodontal disease. The authors illustrated that diabetic patients with poorly controlled conditions were 2.73 times more prone to manifest with periodontal disease associated with high BMI, hypertension, HbA1c ? 7%, and diabetes ailment more than five years linked with intense periodontal disease. Diabetic Mellitus is a disease with the potential to cause disruption of microbial symbiotic equilibrium present in the oral cavity and result in periodontitis which significantly causes reduced quality of life among the affected individuals. Chronic periodontitis has emerged as a diabetes complication alongside poor wound healing, microvascular disease, neuropathy, and retinopathy. Epidemiological studies indicate that the cases of diabetes type 2 are about 285 million, with an estimated increase of fifty percent by 2030, indicating the cases of periodontitis will astonishingly increase and pose a great global health problem (Quadri et al., 2020).
Periodontitis is more common in adults, and an array of mechanisms induced by diabetes mellitus influence the progression of the disease and include elevated pro-inflammatory cytokines, accumulation of advanced glycation end products, altered wound healing, and alteration in the host immune-inflammatory response (Tandon et al., 2015). The disease is a multifactorial condition resulting from multifaceted interactions of harmful environmental exposure, epigenetic influence, inflammatory immune response, and dysbiotic microbiota and currently has a global prevalence of approximately twenty to fifty percent. In the initial stages, it is usually asymptomatic, and on advancement, it is featured by increased tooth loss, tooth migration, and tooth mobility which results in masticatory dysfunction and edentulism, which later affects speech, aesthetics, nutrition, and quality of life (Sanz et al., 2018). Graves et al. (2020) indicates there is strong evidence provided from the association between periodontal disease and type 2 diabetes mellitus with 60 % sex and age-adjusted prevalence of the condition in type 2 diabetes mellitus compared with 36% in individuals without the condition. In addition, type 2 diabetes patients are four times likely to experience severe alveolar bone loss, have a likelihood of 3.4 to experience 25 % radiographic bone loss, and possibly 2.8 times to experience at least 5 mm clinical attachment loss. Periodontitis is currently the sixth most prevalent disease globally with 11.2 % and has caused escalated healthcare burden with indirect costs estimated at $ 25 billion and direct costs of $ 54 billion on a global scale (Nazir & Amin, 2021). These two conditions are inflammation-based, chronic, multifactorial, and complex conditions often occurring in the same individual and have common risk factors including stress, physical inactivity, obesity, unhealthy diet, excessive alcohol consumption, smoking, genetic predisposition, low economic status, minority race, male gender, and higher age.
Hypothesis
The current study hypothesizes that adults with type 2 diabetes mellitus develop periodontal diseases 1.5 times more than healthy adults.
Objectives
The research aims to determine the effects of type 2 diabetes mellitus on developing periodontal disease in adults. It also aims to determine type 2 diabetes mellitus related parameters linked with intense periodontal destruction.
Literature Search
A comprehensive literature search was conducted to solicit journal articles that were used to provide background information and to support the results obtained after research. Only articles published in peer-reviewed journals were included and were obtained from various databases, including PubMed, MEDLINE, google scholar search engines. The search yielded fifteen articles following a thorough analysis, exclusion, and inclusion criteria. Various medical subject headings were employed in search of the articles, such as clinical attachment loss, periodontal disease, type two diabetes mellitus, periodontal assessment, and impact f glucose on the periodontium. The articles were obtained after abstract and title analysis, and only articles published in peer-reviewed journals, human studies, and articles at most seven years old from the date of publication were included in the research. Studies that did not show the impact of type 2 diabetes mellitus on periodontal disease, those that included a mix of animal and human studies, that included more than one type of diabetes mellitus, and those that did not provide analysis of the type 2 diabetes mellitus on periodontal disease participants were excluded from the study.
Statistical Analysis
SPSS software was used to enter and analyze the data, and all the study variables were derived using descriptive statistics. To identify the significant associations existing in the categorical variables, the chi-square test was utilized in addition to the student’s t-test was applied for continuous variables. Clinical periodontal statistical analysis was undertaken to identify disparities in the controls and the diabetics and to identify the disparities between diabetic patients with various complications and diabetes durations. The diabetic individuals with medical problems were regarded as diabetic patients with poor metabolic control history. The presence of diabetic complications may signify the extent of diabetes control over a given time period. After adjustment of confounding between effects, the significant factors in the multivariate analysis were examined using binary logistic regression analysis. Depending on variables, less than fifteen percent of sites with clinical attachment loss of greater or equal to 5 mm were used in the regression model. Independent variables used in the model were having type 2 diabetes mellitus, smoking, gender, and age. P< 0.05 was used as the statistical significance, and Spearman's correlation coefficient was used to assess the association between the quantitative variables. Results The study's standard deviation was 10.58, and the mean age was 49.65, while age ranged between 30 to 68 years. The study included 158 participants with 78 participants as a control group and 80 participants as patients with type 2 diabetes mellitus, and recruitment followed the order of admission. There was no significant difference observed between the controls and the diabetic patients based on the gender distribution and males comprised of 27.8% of controls (p=0.628) and 31.0% of people with diabetes as presented in table 1 having clinical findings, dental history, and demographic features of the study participants (Al-Khabbaz, 2014). The control and study groups presented a statistical difference in their tooth brushing frequency, while both control and diabetic patients had considerably low dental visits frequency, with 45 % of the individuals visiting the dental services for the past year. The diabetic patients had a considerably higher proportion and a number of sites with clinical attachment loss than the control participants (p? 0.01) (table 1) despite them having a lower mean plague score compared to the diabetic-free individuals. Table1: Demographic characteristics of the study participants, dental history, and periodontal findings (Al-Khabbaz, 2014). Type 2 diabetes mellitus and older age were the most significant variables linked with the presence of more severe periodontal destruction sites, as presented in Table 2 illustrating logistic regression analysis of associated factors with having more than fifteen percent of sites with clinical attachment loss ?5mm. Concerning the duration of type 2 diabetes disease, 46.3 % of the diabetic participants had been diagnosed with the disease more than ten years ago, and in the diabetes control, the value of HbA1c %was more than nine percent in 28.8 % of type 2 diabetes mellitus participants. Twenty patients were diagnosed with diabetic complications, with five participants having more than one complication, five had nephropathy, eight had retinopathy, and twelve had neuropathy. 70 % of the participants with medical problems were diagnosed ten years ago with type 2 diabetes mellitus disease. Table 2: Logistic regression analysis of factors linked with having > 15 % of periodontal sites with clinical attachment loss ? 5mm (Al-Khabbaz, 2014).
Participants diagnosed with type 2 diabetes mellitus more than ten years ago and having diabetes complications had a considerable site with 3-4 mm of clinical attachment loss as presented in table 3, illustrating variable mean values depicting the clinical periodontal disease in diabetic patients with different complications and different diabetes duration. Longer type 2 diabetes duration was linked with a higher number of sites with clinical attachment loss ? 5mm.
Table 3: Descriptive statistics of clinical periodontal findings among type 2 diabetes mellitus patients (Al-Khabbaz, 2014).

The association between the number of diagnosed medical conditions and type 2 diabetes mellitus duration with severe periodontal attachment loss are illustrated having increased site percentage with clinical attachment loss ?5mm as confirmed by correlation testing (p=0.007; r=0.321) (Figure 1).

Figure 1: Medical complications and severe attachment loss relationship (Al-Khabbaz, 2014).
Discussion
The present study has demonstrated the detailed periodontal evaluation encompassing six sites per tooth and independent presentation of the percent and the number of sites with severe and moderate clinical attachment loss creating a main strength in the study. To avoid the dilution of the impact of complete tooth loss in the research findings, edentulous patients were excluded; however, the minimum number of teeth in the subjects was set to be seven in each dental arch.
Effects of Diabetes Mellitus on Periodontal Development
The current research has the majority of type 2 diabetes mellitus reporting brushing of teeth at least two times per day and had considerable lower plague scores in contrast with the control groups, although the diabetic patients had equivalent mean bleeding score compared to the non-diabetic participants (table 1) (Al-Khabbaz, 2014). The finding signifies that participants diagnosed with type 2 diabetes mellitus have more extensive periodontal inflammation when compared with healthy participants provided equal plaque buildup amount. Similar studies have revealed the increased severity and periodontitis prevalence in type 2 diabetic Mellitus patients. Hypoglycemia causes impairment in general cell functionality since insulin is needed for glucose entry into cells to act as a source of energy. Plagues function as a local irritant in the oral cavity and contribute to the progression and advancement of periodontal disease. The severity of periodontal diseases is increased in diabetes as contributed by altered sulcular microbial flora, abnormal polymorphonuclear cell function, abnormal collagen metabolism, and angiopathy, which have a close relationship with the severity of the disease in type 2 diabetes patients (Tandonet al., 2015). In response to the plaque as a local irritant, these factors work in a tandem array caused a reduction in the defensive potential of the connective tissues and resulted in disruption of the tissues. A study conducted by Tandonet et al. (2015) demonstrated that severity and distribution of local irritants influence the periodontal disease aggressiveness in diabetic patients, and the blood glucose effects have a direct relationship to the plague formed and are in accordance with the present study.
Earlier suggestion proposes that progression and development of type 2 diabetes mellitus are linked with inflammatory processes since healthy individuals detected with inflammatory markers are later diagnosed with type 2 diabetes mellitus. Type 2 diabetes mellitus is linked with increased levels of systematic inflammatory markers resulting in periodontal tissues inflammation with higher levels of tumor necrosis factor-alpha and interleukin 1-? (Casanova et al., 2015). Individuals with diabetes experience an accumulation of advanced glycation end products, oxidative stress, and reactive oxygen species in the periodontal tissues, resulting in elevated inflammation in diabetic patients. In addition, diabetic patients potentially harbor more aggressive lethal bacteria than healthy individuals, such as T. forsythensis and P. gingivalis observed from diabetic patients’ plague. As demonstrated, even in lower levels of bacterial growth as contained in the plague, diabetes patients have a greater likelihood of developing periodontal disease than healthy subjects.
The current findings illustrate that type 2 diabetes patients had considerable mean percent and the number of sites with clinical attachment loss ? 3mm in comparison to non-diabetic patients, and the disparities existing in the two groups increased for sites with clinical attachment loss ? 5mm as presented in table 1 (Al-Khabbaz, 2014). A study performed by Oyapero et al. (2019) affirmed that an increase in glycemic parameters contributed to the significantly worse pocket depth and attachment loss in patients with type 2 diabetes mellitus. The underlying mechanisms resulting in increased prevalence of periodontal diseases in diabetic patients range from the binding of advanced glycation end-products to the cell receptors, accumulation of advanced glycation end-products that stimulate oxidative stress in tissues, and increased vulnerability to infection the reduction of functionality of neutrophils. In the advanced stages, the involvement of periodontal disease in diabetic patients greatly results in gingival recession, drifting teeth, decreased masticatory efficiency, tooth mobility, contributing to reduced social acceptance and poor esthetics. In the case of untreated conditions, tooth loss ensues, and deterioration of the affected individuals is imminent, especially when the anterior teeth are affected and speech problems that greatly impact the patient’s quality of life. In well-controlled type 2 diabetes mellitus, patients have equivalent periodontal status compared to non-diabetic healthier patients, indicating glycemic control is central in managing and preventing periodontal disease.
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Type 2 Diabetes Mellitus Related Parameters that are Linked with Intense Periodontal Destruction
The current study has revealed that a longer duration of type 2 diabetes mellitus increases the prevalence of moderate to severe clinical attachment loss sites with the considerable correlation between the site percentage with ?5mm and duration of type 2 diabetes mellitus (Table 3). When a comparison between healthy non-diabetic individuals and type 2 diabetes mellitus is performed, the severity level of periodontal disease is 1.5 times higher in participants with type 2 diabetes mellitus. In a study conducted by Kim et al. (2020), analysis of the effects of diabetes index was performed using insulin parameters, fasting blood glucose, and glycated hemoglobin on periodontal disease. The study illustrated that the periodontal disease index was greater in diabetic patients than normal participants, and normal individuals had enhanced periodontal disease status. It was observed that an increase in HbA1c resulted in exacerbations of periodontal disease in normal individuals while the normal participants lacked diabetic index on periodontal disease, thereby concluding that deterioration of periodontal diseases occurs on diabetes disease presentation. Glycated hemoglobin levels are crucial for routine diabetic management utilized as a risk indicator and long-term blood glucose control index. Diagnosis of diabetes widely utilizes glycated hemoglobin concentration; as a result, it has a considerable impact as the only diabetic index closely linked with periodontal disease.
Tooth loss has been significantly associated among diabetic individuals with severe periodontal disease, and it is more prevalent than in healthy people. Type 2 diabetes mellitus with periodontal disease has a considerably lower mean teeth number than type 2 diabetes mellitus free from periodontal diseases. The impact of periodontal disease with consequent teeth loss can influence the individual’s ability to maintain glycemic control and maintain a healthy diet which negatively impacts the quality of life. Diabetes mellitus is implicated in the pathogenesis of periodontal disease through the enhancement of alveolar bone metabolism abnormalities. The osteoblasts and osteoclasts are affected by diabetes conditions in the periodontium through increased levels of reactive oxygen species and advanced glycation end products, and elevation of inflammatory markers expression (Nazir & Amin, 2021). The number of bone-forming fibroblasts and osteoblasts is reduced significantly in diabetes and increases bone cell apoptosis via increased production and interaction of reactive oxygen species. Bone healing is affected due to elevated osteoblasts apoptosis, thus affecting the constitution of periodontal tissue and subsequent tooth loss due to diminished support.
The current study indicates that individuals with more sites with 3-4 mm of clinical attachment loss were significantly associated with having at least one diabetic complication, the uncontrolled diabetic condition results in advanced systemic complications stemming from severe forms of periodontal destruction. Similar studies elucidated the impact of social demographic features on the development and progression of periodontal disease in diabetic patients and showed that age advancement is a key contributor to periodontal disease extension (Hasan et al., 2021). The explanation for this observation revolves around the fact that tissue integrity and immune function deteriorates with age advancement and exposes patients to periodontal disease susceptibility. Oral hygiene and self-care practices significantly contribute to outcomes related to periodontal disease in conjunction with the clinical determinants related to diabetes. Poor glycemic control has an independent adverse link with severe forms of periodontal disease; oral hygiene has far-reaching implications in increasing the risk of the condition. Individuals with poorly controlled diabetes conditions and practicing fair or poor oral hygiene norms are more likely to develop the severe periodontal disease compared t individuals practicing poorly controlled diabetes and good oral hygiene. Individuals performing fair or poor oral hygiene behaviors and poorly controlled diabetes adversely elevate the risks of developing any severe form of periodontal disease.
Diabetic patients with fair knowledge of good oral hygiene practices and periodontal risk factors have lower risks of developing severe periodontal disease forms. Proper oral health knowledge such as consumption of carbonated drinks increases the risk for the disease, and regular brushing reduces the periodontal disease risks or hygiene practices such as brushing more than two minutes use of fluoridated toothpaste or rinsing the mouth after meals are linked with reduced periodontal disease prevalence. In addition, the impact of healthcare providers mandated with diabetes treatment is considered in addressing the needs of oral health for their patients. In contrast, most healthcare providers tasked with diabetes treatment fail to discuss oral health matters during patient visits. As a recommendation for assessing periodontal health, healthcare providers’ awareness is essential in improving behavior and attitude towards diabetic patient management (AlShwaimi et al., 2019). Most diabetic patients fail to recognize the impact of their condition on their oral health and lack of required awareness on how to reduce the risk of periodontal diseases and enhance their oral health status.
In summary, the current study has vividly expounded the association between the severity of periodontal disease and type 2 diabetes mellitus when compared to healthy or non-diabetic participants. The evidence demonstrated throughout the study is enough to accept the hypothesis that adults with type 2 diabetes mellitus develop periodontal diseases 1.5 folds compared to healthy adults. The bidirectional relationship between the two conditions has been elucidated clearly, and periodontal disease is a significant complication of type 2 diabetes mellitus. Integration of periodontal examination and subsequent therapies is essential in diabetic patient management. Considering the irreversible effects of the disease, patient education is essential to ensure the awareness is enriched to improve oral health and effective glycemic control. Self-care practices are instrumental in oral hygiene practices and diabetes control since poorly controlled diabetes has an adverse link with any kind of severe periodontal disease. Management of these two conditions requires an interdisciplinary approach to ensure a collaborative approach is instilled in healthcare systems to control the two disease conditions effectively. Since proper patient management involves the contribution of physicians and dentists, oral healthcare providers require an understanding of the therapeutic and diagnostic modalities employed in diabetes care. Therefore, a clear bridge of care is needed between the physicians and oral healthcare providers on the interrelationship existing between glycemic control and periodontal health with the possible systemic infections arising from these infections coupled with the inflammatory nature. A comprehensive approach entailing oral healthcare and diabetes practitioners is necessitated to control and prevent periodontal disease in diabetic patien

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