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ORIGINAL RESEARCH
Year : 2013  |  Volume : 17  |  Issue : 5  |  Page : 592-596  

Evaluation of thickness of cementum of periodontally diseased teeth of non-diabetic and type 2 diabetic patients: A scanning electron microscopy study


1 Department of Periodontics, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
2 Department of Periodontics, Vokkaligara Sangha Dental College and Hospital, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India
3 Department of Oral Pathology, Krishnadevaraya College of Dental Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India
4 Department of Oral Pathology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission17-Apr-2012
Date of Acceptance05-Aug-2013
Date of Web Publication4-Oct-2013

Correspondence Address:
Radhika Gupta
54, Old Vijay Nagar Colony, Agra - 282 004, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.119280

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   Abstract 

Background: It is suggested that diabetes plays an important role in tooth loss. The periodontal structure and alveolar bone architecture in diabetics have revealed alterations. However, changes in cementum of diabetics with periodontal disease have not been evaluated adequately. Thus, the aim of the study is to evaluate and compare the thickness of cementum in diseased and healthy areas of roots of teeth with chronic periodontitis from non-diabetic (group I) and type 2 diabetic patients (group II). Materials and Methods: Thirty incisors indicated for extraction as a result of chronic periodontitis from group I and group II were selected. Measurements of Probing Depth (PD) and Clinical Attachment Loss (CAL) were taken prior to extractions. Area of the root surface above the CAL (notch) was designated as diseased, while the area below the CAL (notch) was designated as healthy. The extracted tooth samples were sectioned longitudinally and were evaluated by scanning electron microscopy (SEM). Descriptive statistical analysis was performed. Results of continuous measurements were presented as Mean ΁ SD. Results: The results showed that in both groups the thickness of cementum in diseased areas was lower in comparison to the thickness in healthy areas. The mean thickness of cementum in both healthy and diseased areas was higher in group II compared to group I, though the differences in both were not statistically significant. Conclusion: Within the limits of the present study, group II showed greater mean thickness of cementum in both healthy and diseased areas compared to group I, though the differences were not statistically significant.

Keywords: Advanced chronic periodontitis , non diabetics, scanning electron microscopy, thickness of cementum, type II diabetics


How to cite this article:
Gupta R, Galgali SR, Bavle RM, Chandavarkar V. Evaluation of thickness of cementum of periodontally diseased teeth of non-diabetic and type 2 diabetic patients: A scanning electron microscopy study. J Indian Soc Periodontol 2013;17:592-6

How to cite this URL:
Gupta R, Galgali SR, Bavle RM, Chandavarkar V. Evaluation of thickness of cementum of periodontally diseased teeth of non-diabetic and type 2 diabetic patients: A scanning electron microscopy study. J Indian Soc Periodontol [serial online] 2013 [cited 2020 May 29];17:592-6. Available from: http://www.jisponline.com/text.asp?2013/17/5/592/119280


   Introduction Top


Periodontitis is the disease of the tooth supporting tissues. Alterations in the supporting tissue develop in response to bacteria in subgingival plaque. Interactions of connective tissue cells chiefly fibroblasts with numerous inflammatory mediators and cytokines present at the site of injury initiate an inflammatory response that destroys the collagenous and non-collagenous proteins in the extracellular matrix of the periodontium. This leads to attachment loss and bone resorption. Cementum of the root becomes exposed to the environment of periodontal pocket or the oral cavity and alterations may occur within exposed hard tissue. Structural and compositional changes in the matrix components of cementum have been reported in patients with periodontitis. [1],[2] Significant evidence supports a strong correlation between periodontal disease and diseased or altered cementum.

A number of systemic conditions may affect the host's immune response to oral pathogens and may exacerbate the periodontal disease. Diabetes mellitus, a chronic metabolic disorder that constitutes a major worldwide health problem, is one such condition. Many systemic complications such as micro- and macro-angiopathies, neuropathy, and nephropathy are recognized as common complications of diabetes. Periodontal disease has been recognized as the sixth complication of diabetes. In large populations, type 2 diabetes has been shown to be a significant risk factor for periodontitis. Changes in gingiva, alveolar bone, and periodontal ligament have been reported in diabetics. Tendency toward enlarged gingivae, sessile or pedunculated gingival polyps, polypoid gingival proliferations, abscess formation, periodontitis, and loosened tooth are the most frequent findings. [3] High levels of glucose present in the crevicular spaces of diabetics for extended period of time can adversely affect the periodontal ligament (PDL) cell function. Changes in the density and mineralization of Sharpeys fibers on the depository surfaces of alveolar bone have been reported in streptozotocin-induced diabetic Swiss mice. [4] Inhibition of collagen matrix formation, increased time for mineralization of osteoid, and reduced bone turnover have also been reported in diabetes.

However, changes in cementum have received little attention, probably because cementum of root was considered an inactive or unresponsive tissue. Histologic sections of human teeth provide evidence that cementum of the root surface is not inactive. It is affected by changes in immediate environment as evidenced by the root surface alterations that occur in periodontitis. [5],[6] Defect in defense mechanism may facilitate entry of bacteria and bacterial substances into cementum producing altered root surfaces. Formation of advanced glycated end products in response to elevated glucose concentration may modulate the function of cell residing in periodontal ligament altering its ability to repair or regenerate the mineralized tissue. [7],[8]

Therefore, the aim of the present study was to evaluate and compare the thickness of cementum in diseased and healthy areas of roots of teeth with advanced chronic periodontitis from non-diabetic and type 2 diabetic patients.


   Materials and Methods Top


A comparative observational study was carried out to evaluate and compare the thickness of cementum in diseased and healthy areas of roots of teeth with chronic periodontitis from non-diabetic and type 2 diabetic patients.

Twenty-two males and eight females were included in the study. The mean age of the participants was 48.4 years. An informed consent of all the subjects who participated in this investigation was obtained after the possible discomforts, risks, and procedures were fully explained.

Thirty root specimens, 15 from non-diabetic (group I), and 15 from diabetic patients (group II) with chronic periodontitis indicated for extraction were selected. Out of the 30 specimens, 19 were central incisors (14 maxillary and 5 mandibular) and 11 lateral incisors (8 maxillary and 3 mandibular incisors).

Inclusion criteria for group I

  • Diagnosed as chronic periodontitis
  • No previous history of root planning and periodontal flap surgery received by the patient
  • Vital teeth with no caries or filling or restoration
  • Grade III mobility and presence of available bone support, according to the radiography, not exceeding one third of root length.


Inclusion criteria for group II

  • Diagnosed as chronic advanced periodontitis
  • Patients with type 2 diabetes with a history of diabetes of ranging from 4 to 6 years
  • No previous history of root planning and periodontal flap surgery received by the patient
  • Vital teeth with no caries or filling or restoration
  • Grade III mobility and presence of available bone support, according to the radiography, not exceeding one third of root length.


Exclusion criteria for group I

  • Patients with any systemic diseases or prejudicial habits (tabagism)
  • Teeth with caries and subgingival restorations
  • Fractured tooth
  • Root canal treated tooth
  • Teeth in hypofunction - missing antagonist, submerged teeth.


Exclusion criteria for group II

  • Diabetic Patients with any other systemic diseases or prejudicial habits (tabagism)
  • Teeth with caries and subgingival restorations
  • Fractured tooth
  • Root canal treated tooth
  • Teeth in hypofunction-missing antagonist, submerged teeth.


Patients fulfilling the above criteria were included in the study. Following local infiltrative anesthesia, with 2% lignocaine with 1:80,000 adrenaline, the level of the gingival margin was marked using a diamond bur.

Clinical attachment level (CAL) and probing depth (PD) measurements were done. All clinical measurements were taken to nearest 0.5 mm using UNC-15 probe following which the tooth was extracted. Care was taken during extraction not to damage root surface. After the extraction, CAL was marked by the notch on the extracted tooth using a diamond bur. Area of the root surface above the CAL (notch) was designated as diseased while the area below the CAL (notch) was designated as healthy. All the teeth were washed with 0.1 M sodium phosphate buffer immediately after extraction. The teeth were then fixed with buffered 10% formaldehyde for 48 hours to preserve biofilm coating. The tooth samples were then sectioned corono apically in mesiodistal plane using a thin diamond disc mounted on a slow speed hand piece with distilled water as a coolant solution [Figure 1]. One half of each specimen was dehydrated in ascending strengths of ethanol to 100% and mounted on to brass metal stub. This procedure was followed by gold sputtering with Edwards S150 SPUTTER COATER. The samples were examined in a LEO 435 VP SEM.
Figure 1: Schematic drawing of the sectioning procedure

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Examination was performed above and below the notch (clinical attachment level) [Figure 2]. The micrographs were obtained at ×200 magnification. [9]
Figure 2: Schematic drawing of the evaluated root section

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By using these micrographs, the thickness of the cementum layers for the healthy and diseased part was measured at three different sites and the average value was calculated [Figure 3],[Figure 4],[Figure 5] and [Figure 6]. One examiner performed all of the morphological evaluations. The same examiner repeated the readings 3 weeks later in order to evaluate the intraexaminer agreement.
Figure 3: Measurement of thickness of cementum in non-diabetics (group I) at healthy area (×200)

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Figure 4: Measurement of thickness of cementum in non-diabetics (group I) at diseased area (×200)

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Figure 5: Measurement of thickness of cementum in diabetics (group II) at healthy area (×200)

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Figure 6: Measurement of thickness of cementum in diabetics (group II) at diseased area (×200)

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Descriptive statistical analysis was carried out in the present study. Results of continuous measurements were presented as Mean ± SD (Min-Max) and results of categorical measurements were presented in Number (%). Significance was assessed at 5% level of significance. The Student t test (two tailed, independent) was used to find the significance of study parameters on continuous scale between two groups (group I and group II) and the Student t test (two tailed, dependent) was used to find the significance of study parameters on continuous scale within each group (above the notch and below the notch).


   Results Top


Fifteen root specimen from non-diabetic (group I) and 15 root specimen from diabetic patients (group II) were evaluated with SEM. The mean age of patients was 48.4 years, (non-diabetic patients: 43 years and diabetic patients: 53.8 years) of which 73.3% were males and 26.7% females (22 males, eight females). The mean values of PD and CAL for group I was 2.33 ± 1.59 mm and 4.80 ± 1.14 mm, respectively. The mean values of PD and CAL for group II was 3.07 ± 1.53 mm and 5.53 ± 1.59 mm, respectively. Although the mean values for PD and CAL were higher in group II compared to group I, the differences were not statistically significant.

The mean thickness of cementum in group I in healthy areas was 93.04 ± 25.44 μm (53.95-133.72 μm) while in diseased areas was 89.77 ± 22.47 μm (45.34-132.95 μm).

The mean thickness of cementum for group II in healthy areas was 105.38 ± 41.34 μm (55.95-133.72 μm) and in diseased areas was 104.11 ± 38.18 μm (50.58-168.50 μm).

The value of thickness of cementum in both group I and II was higher in healthy areas compared to diseased areas although the differences were not statistically significant. Thickness of cementum in both healthy and diseased areas was higher in group II as compared to group I, but was not statistically significant. Thus, irrespective of the type of specimen, the thickness of cementum was found to be higher in healthy areas compared to diseased areas, but was not statistically significant.


   Discussion Top


Cementum is a thin layer of mesenchymal tissue covering the dentine of the root and is one of supporting tissues of the periodontium. The other tissues that support the tooth are the alveolar bone and the periodontal ligament. Cementum is the least understood of these tissues. [9]

Periodontitis is the most common form of destructive periodontal disease. It is characterized by an inflammatory process that gradually spreads in an apical direction, causing resorption of alveolar bone as well as loss of soft tissue attached to the tooth. It is believed that 5% to 10% of the adult population is affected by severe periodontitis. [10] The disease usually begins at around the age of 40 and progresses slowly with periods of exacerbation and remission. [11] A number of systemic factors modify the course of disease and diabetes mellitus is one of them. Alterations in periodontium have been reported in patients with type 2 diabetes. Gingival changes, changes in the alveolar bone and periodontal ligament have been described. However, changes in cementum have received little attention. [9]

Cementum is a biologically responsive tissue affected by environmental stimuli and may undergo alterations as a result of pathologic changes in the immediate environment. [3] Therefore, the aim of the study was to evaluate and compare the changes in the thickness of root surfaces of teeth with advanced chronic periodontitis from non-diabetic and diabetic patients.

Thirty root specimens, 15 from non-diabetic (group I) and 15 from diabetic patients (group II) with advanced periodontitis were included in the study. Maxillary and mandibular incisors were chosen for convenience and uncomplicated root anatomy. The mean age of participants was 48.4 years. The two groups did not differ with respect to PD and CAL, allowing the assumption of homogenecity of patient population. Diabetic patients with a history of diabetes of ranging from 4 to 6 years were included in the study. Degree of metabolic control and duration of diabetes have been closely associated with periodontal disease severity. [11] Patients in whom diabetes was uncontrolled as determined by fasting blood glucose ≥70 to 110 mg/dl were referred to physician. Their diabetic status was controlled prior to extraction.

A number of tools have been used for assessing the thickness of diseased root surfaces. Decalcification of the root specimens for analysis under light microscopy is the most commonly used methodology. [12] Scanning electron microscopy also represents a qualitative method for assessing the root surface. SEM is a tool which gives three-dimensional pictures at ultra-structural level. [13] Standardized photomicrographs were obtained at ×200. The thickness of the sectioned surfaces was examined using the photomicrographs.

The thickness of cementum is affected by various factors such as tooth type, history of eruption, function, and age of individual. [9] To eliminate the effect of these factors, areas above the clinical attachment level as identified by a notch were designated as diseased while that below the notch were designated as healthy. Thus, each tooth served as its own control for studying the diseased and healthy cementum.

Following careful extraction of teeth, the root specimens were sectioned longitudinally, so that the labial and lingual surfaces of the teeth were available for study. Mesial or distal sites were not used for evaluating the thickness of cementum as it has been found that the mean cementum width on the mesial side of the root is slightly less than on the distal side which seems to represent a functional effect related to mesioocclusal migration of the teeth. [14] Rate of development of extrinsic cementum at distal sites has been shown to be three times than at mesial sites. [15] Thus, the thickness of cementum was assessed only on the labial aspect of tooth.

Cementum varies in thickness at different parts of the root. Cementum thickness is higher at cervicopalatal areas and apicolabial surfaces of maxillary single rooted teeth and at cervicolabial and apicolingual surface of mandibular single rooted teeth. In this study, measurement of thickness was done at three different areas in healthy and diseased portions of the roots and average of each was taken. In this study, the mean values of thickness of cementum in diseased areas were lesser than in healthy areas, both in non-diabetic and diabetic patients. The results of this study are in agreement with an earlier study which revealed a significant decrease in the thickness of cementum on the diseased root surfaces compared to the healthy surfaces. [9]

The decrease in thickness of cementum in diseased areas of root surfaces is attributed to decrease or loss of collagen cross-banding at or near the cemental surfaces. The possible mechanisms for the collagen decrease or loss are action of collagenase and other proteolytic enzymes responsible for the breakdown of collagen in surrounding connective tissue before cementum is exposed and to the action of bacteria and salivary enzymes producing the changes after cementum is exposed to the oral environment. [9] Interruption of continuous cementum deposition during inflammatory process by altering the environment from the healthy to diseased sites affects the physiologic deposition of cementum. [9] Reduction of periodontium by marginal periodontitis may result in destruction of progenitor cells which have the potential to form essential structural components of the periodontium. [16] These factors could have been responsible for the decreased thickness of cementum in diseased areas of the root.


   Conclusion Top


Thus, within the limits of the present study it can be concluded that the mean thickness of cementum in diseased area was less in comparison to mean thickness of cementum in healthy areas in both group I and group II although the differences were not statistically significant. The mean thickness of cementum was higher in group II compared to group I in both healthy and diseased areas although the differences were not statistically significant.

 
   References Top

1.Komboli MG, Kodovazenitis GJ, Katsorhis TA. Comparative immunohistochemical study of the distribution of fibronectin in healthy and diseased root surfaces. J Periodontol 2009;80:824-32.  Back to cited text no. 1
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2.Lao M, Marino V, Bartold PM. Immunohistochemical study of bone sialoprotein and osteopontin in healthy and diseased root surfaces. J Periodontol 2006;77:1665-73.  Back to cited text no. 2
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3.Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza′s Clinical Peridontology. 10 th ed. St. Louis, Missouri: Saunders Elsevier; 2007.  Back to cited text no. 3
    
4.Johnson RB. Morphological characteristics of the depository surface of alveolar bone of diabetic mice. J Periodont Res 1992;27:40-7.  Back to cited text no. 4
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5.Craig RG. Cementum versus bone: An experimental perspective. Oral Maxillofac Surg Clin North Am 1997;9:581-95.  Back to cited text no. 5
    
6.Emslie RD. Some considerations on the role of cementum in periodontal disease. J Clin Periodontol 1978;5:1-12.  Back to cited text no. 6
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7.Sznajder N, Carraro JJ, Rugna S, Sereday M. Periodontal findings in diabetic and nondiabetic patients. J Periodontol 1978;49:445-8.  Back to cited text no. 7
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8.Shlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type 2 diabetes mellitus and periodontal disease. J Am Dent Assoc 1990;121:536.  Back to cited text no. 8
    
9.Bilgin E, Gurgan CA, Arpak MN, Bostanci HS, Guven K. Morphological changes in diseased cementum layers: A scanning electron microscopy study. Calcif Tissue Int 2004;74:476-85.  Back to cited text no. 9
    
10.National Institute of Dental and Craniofacial Research: Periodontal Disease in Adults (Age 20 to 64). Available from: http://www.nidcr.nih.gov/datastatistics/finddatabytopic/gumdisease/periodontaldiseaseadults20to64.htm (Data from 1999-2004).  Back to cited text no. 10
    
11.Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontology 2000 2007;44:127-53.  Back to cited text no. 11
    
12.Gokhan K, Keklikoglu N, Buyukertan M. The comparison of the thickness of the cementum layer in Type 2 diabetic and non-diabetic patients. J Contemp Dent Pract 2004;5:124-33.  Back to cited text no. 12
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13.Garrett JS. Cementum in periodontal disease. Periodontal Abstr 1975;23:6-12.  Back to cited text no. 13
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14.Louridis O, Bazopoulou-Kyrkanidou E, Demetriou N. Age effect upon cementum width of albino rat: A histomertic study. J Periodontol 1972;43:533-6.  Back to cited text no. 14
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15.Dastmalchi R, Poison A, Bouwsma O, Proskin H. Cementum thickness and mesial drift. J Clin Periodontol 1990;17:709-13.  Back to cited text no. 15
    
16.Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med 2002;13:474-84.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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