Introduction

Diabetes mellitus (DM) is a group of metabolic disorders with serious complications reducing the quality of life [ 1- 2]. It is caused by the absolute or relative insulin deficiency due to decreased secretion of this hormone from the pancreas (type-1 DM) or insensitivity of environmental receptors to this hormone (type-2 DM) [ 3]. The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people) [ 4]. Type-1 DM usually occurs in childhood, and adolescence includes 5-10% of all diabetes patients [ 3].

Periodontal diseases and gingivitis were reported as the sixth most common complication of diabetes, which are usually associated with the severity of disease [ 5- 6]. Some studies showed more prevalence of gingival inflammation in children and adolescents with type-1 DM compared to the healthy population [ 7- 9].

The use of saliva instead of serum has recently been preferred as a diagnostic medium. Saliva offers advantages over blood because it is a cost-effective and non-invasive method that can be collected by persons with modest education [ 10]. One approach to early diagnosis of periodontitis is the salivary biomarkers. Some biomarkers, such as cytokines, were diagnosed and proposed in the literatures [ 11- 13].

Accumulation of reactive oxygen species, oxidative stress, and interactions between advanced glycation end products (AGEs) in the periodontal tissues and their receptor (RAGE) all contribute to increased inflammation in the periodontal tissues in people with DM [ 14]. There is also a lipid metabolism disorder in diabetic patients due to impaired glucose metabolism and changes in insulin secretion and activity. As a result of systemic lipid disorders, high concentrations of lipids have been shown in these patients' blood and saliva. Lipids play the role of nuclei in the dental plaque mineralization and accelerate the activity of the enzyme glucosyltransferase, which is responsible for the carcinogenic activity of oral microorganisms. High cholesterol and triglyceride levels in the plaque, delay the release of lactic acid from it. The presence of lipids in the saliva modulates bacterial hydrophobic surfaces and thus helps to bind them to dental surfaces [ 14- 15].

Salivary albumin is regarded as a serum ultrafiltrate to the mouth, and it may diffuse into the mucosal secretions. Hormonal balance, nutrition, and osmotic pressure regulate albumin synthesis. High concentrations of salivary albumin have been detected in a medically compromised condition, such as immunosuppression and DM. Both normal and raised salivary albumin levels have been seen in periodontitis [ 16- 17].

In association with α -amylase, some studies have suggested that this salivary enzyme contributes to the microorganisms’ adhesion and the microbial plaque formation; however, other studies have found that α-amylase secretion is associated with a reduced risk of caries, a decrease in oral bacteria, and a reduced risk of periodontal disease [ 18- 20]. DM can affect the composition and flow of saliva. These changes in saliva can be involved in the onset of symptoms and even the severity of oral complications in diabetic patients [ 21]. Many studies have been done about the correlation between salivary composition and periodontal disease in DM, but the results have not been conclusive. Regarding the few studies conducted in this field concerning quality control of the disease, the present study performed to investigate the relationship between periodontal status and salivary protein, lipid, and antioxidant capacity in healthy individuals and patients with well-controlled and uncontrolled type-I DM.

Materials and Method

Study population

This cross-sectional study performed on 6- to 16-year-old diabetic and healthy volunteers with normal body mass index (BMI; percentile 5-85%) (Figure 1) [ 22].

Figure 1. Individual growth chart 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, 97th percentiles, 2 to 20 years: body mass index-for-age [ 22]

Based on previous studies [ 23- 24] and considering an alpha coefficient of 0.05 and a statistical power of 0.8, the sample size was determined to be 120 (case group; n=60 and control group; n=60). The case was divided into two subgroups of well-controlled DM (n=33) and poorly-controlled DM (n=27).

The case group has consisted of patients who were diagnosed with type-1 DM by an endocrinologist at the Amirkola Children Hospital for at least three years. The quality of control of disease was determined based on the level of HbA1c. Patients with HbA1c more than 7.5% were considered into poorly-controlled DM group [ 25]. The patients were selected through a simple sampling method considering the exclusion criteria, such as having other diseases (asthma, cardiovascular disease, epilepsy, and renal deficiency) and reluctance to participate in the study.

The control group included healthy individuals who had not taken any medicine over the last month [ 26]. They were selected from schools of Babol city (north of Iran) using multistage random sampling. According to the different socio-economic situations in various urban districts and their impact on health and nutrition, a multistage sampling method can be generalized to the whole town. However, in the case of patients, because there is only one children's hospital in the city, all the patients can be found in the same place. The subjects in both groups were matched for age and gender.

Ethical considerations

The study was approved by the Ethical Committee of the Research Council of Babol University of Medical Sciences (MUBABOL.REC.1395.55). The written consent was obtained from all subjects or their parents.

Experimental procedure

Personal information and medical history of patients were obtained through interviewing participants/ parents and their medical records. In order to minimize the effect of the circadian rhythm, all saliva samples were collected from 10 to 11 AM, and then oral examination was done. Unstimulated saliva samples were collected in disposable sterile tubes and immediately transferred to the laboratory in a container containing dry ice at -4°C. The samples were centrifuged at 1500 g and 15 minutes, Clement 2000, North Sydney, Australia), the supernatant was collected into Eppendorf microtubes and were stored at -80°C until analyzes.

Measurement of a lipid profile

Salivary cholesterol and triglyceride levels were assessed based on the colorimetric method using ZiestChem commercial kits (ZiestChem Diagnostics Co.; Iran) according to the manufacturer's protocol [ 27].

Measurement of α-amylase activity

In order to measure the α-amylase activity, 500µl of reagent was poured into the blank and the sample tubes and incubated at 37ºc for 5min. Then 20µl of the sample was added to the sample tube and incubated at 37ºc for 15min. Then immediately after that, the chemical reaction was stopped by adding 500 µl Iodine solution and 1500 µl distilled water. The absorption for the blank and the sample tubes was compared against distilled water at 405nm using UV-visible spectrophotometer, and α-amylase activity was estimated by this equation [ 28]:

Absorbance of blank-Absorbance of sample Absorbance of blank×1470= α-Amylase activityUL

Measurement of total protein and albumin concentration

Salivary total protein was measured in the Biuret method using ZiestChem commercial kits (ZiestChem Diagnostics Co., Iran) according to the manufacturer's protocol. Salivary albumin levels were measured based on colorimetric assay using the ZiestChem commercial kit (ZiestChem Diagnostics Co., Iran) also [ 29- 30].

Measurement of FRAP and DPPH indexes

Total antioxidant capacity (TAC) of salvia was measured according to Ferric Reducing Ability of Plasma (FRAP) assay, and the free radicals scavenger index was measured by DPPH assay (1.1-Diphenyl-2-picryl-hydrazyl) [ 31- 32]. Löe and Silness gingival index (GI) and Silness and Löe plaque index (PI) were measured [ 33]. A senior dental student, using a dental mirror and a probe on a chair and in ambient light, did oral examination.

Statistical analysis

Data were statistically analyzed by Kruskal-Wallis followed by the Mann-Whitney U Test, One-way analysis of variance (ANOVA), Tukey Scheffe, t test, and Pearson correlation test in SPSS-22. All statistical tests were performed at the significance level of the p value less than 0.05.

Results

The mean ages of the subjects in case and control groups were respectively 10.02±1.39 and 10.07±0.82 years. Thirty-three diabetic patients (55%) were diagnosed with well-controlled DM (HbA1c less than 7.5%); approximately 4.45±2.43 years elapsed from the diagnosis of DM. The levels of salivary triglyceride and cholesterol, amylase, and GI in people with DM were significantly higher than that in healthy subjects (p< 0.001, Table 1).

Albumin and total proteins in healthy subjects were significantly higher than that in people with DM (p< 0.001, Table 1). There was not a significant difference in the amount of salivary antioxidant capacity and PI between healthy and diabetics individuals (Table1).

In terms of gender, the level of salivary lipids and total proteins in both males (p= 0.00) and females of non-diabetic subjects were significantly higher than those of diabetic subjects (p< 0.001). Salivary α-amylase activity in both males and females of the case group was significantly higher than that of the control group (p< 0.001). Salivary albumin in diabetic men was significantly lower than that of healthy ones (p<0.001).

Nevertheless, no significant difference was found between the salivary albumin level of diabetic and non-diabetic females (p= 0.11).

Table 2 illustrates the mean and standard deviation or median of study variables in the well-controlled DM and poorly-controlled DM and non-diabetic groups (Table 2). No significant correlation was found between all salivary parameters and gingival status (Table 3).

Discussion

This study aimed to evaluate the level of salivary lipids and proteins and TAC of patients with type-1 DM and their correlation with gingival health status compared to healthy children. In the present study, a higher GI was found in diabetic patients compared to non-diabetics. However, there was no significant difference in the PI of study groups. So, gingival inflammation in these patients seems not to be related to oral hygiene.

Similar to this result, Alves et al. [ 34] indicated a significant increase in the GI of diabetic patients compared to healthy individuals despite a non-significant difference in plaque index. Machado et al. [ 35] found no significant difference between GI of diabetic and non-diabetic subjects, despite a higher PI in patients with DM. The published data on the exclusive influence of microbial plaque on gingival inflammation in patients suffering from type-1 DM are controversial [ 36]. Pathogenesis of DM in gingivitis and periodontitis can be attributed to factors such as small vessels involvement, changes in gingival fluid composition and elevation of inflammatory mediators [ 37], changes in collagen metabolism, decreased defense responses, the increased presence of periodontal pathogenic microorganisms and oxidative stress [ 38] and genetic predisposition to non-enzymatic glycosylation [ 36]. A positive correlation was shown between periodontitis and GI and gingival bleeding/ dental biofilm by Daković and Pavlović [ 36]. They suggested these items as the prognostic indicator of potential periodontitis.

In the present study, the GI of poorly-controlled diabetic children was significantly higher than that of healthy children. Available literature data illustrated a correlation between the incidence and severity of gingival inflammation and poor metabolic control of DM [ 36]. So, control of DM seems to be critical to the prevention of gingival and periodontal disease.

Sadeghi et al. [ 39] showed a higher level of GI in the 13-18 year old diabetic patients, but they found no relationship between the HbA1c level and periodontal indices.

Salivary cholesterol and triglyceride of diabetic patients were estimated lower than that of non-diabetic patients. In contrast, Priya et al. [ 4] found a higher level of salivary lipids (cholesterol and triglyceride) in patients with type-1 DM, which might be due to demographic and racial differences.

In the present study, a higher level of salivary α-amylase was found in DM patients compared to healthy subjects. However, a higher level of salivary total proteins and albumin were observed in healthy individuals. Lakshmi et al. [ 41] showed a higher level of salivary total proteins and α-amylase in patients with DM. Panchbhai et al. [ 42] studied on salivary total proteins, and α-amylase of well-controlled and poorly-controlled DM patients compared with healthy individuals and showed a significantly lower level of salivary α-amylase in patients with well-controlled DM compared to healthy subjects. However, no significant differences were found between other variables and groups. In the present study, no significant difference was found between well-controlled and poorly-controlled groups about the salivary proteins levels.

The TAC measured by FRAP and radical scavenger index determined by the DPPH assay were not significantly different among study groups. In contrast, Basir et al. [ 43] used the TAC kit for measuring the level of salivary antioxidants and reported that patients with type1 DM had less antioxidant defense compared to healthy children. A different method for measurement of salivary antioxidants can be a reason for different results. Astaneie et al. [ 44] reported no significant difference between the level of reactive thiobarbituric acid as a lipid peroxidation marker in diabetics and the control group. In a study conducted by Gümüş et al. [ 45], the mean salivary reduced-glutathione concentration in type-1 diabetic patients was estimated lower than that of healthy subjects, but there was no significant difference in the concentration of other antioxidants among different groups. Rai et al. [ 46] estimated the phosphomolydic acid in saliva using spectrophotometry and showed that salivary antioxidant level was lower in diabetic patients than that of healthy individuals.

In the present study, it was found no significant correlation between GI and PI and TAC. Aral et al. [ 47] reported that the oxidative stress index in diabetic patients was higher than that of the control group. However, it decreased after initiating treatment for DM, and instability in oxidative conditions with DM may be a significant contributor to periodontal disease.

In the study conducted by Reznick et al. [ 48], there was a strong correlation between the severity of DM and the increase of salivary and serum antioxidants such as peroxidase and superoxide dismutase. Overall, measuring the antioxidant agents by different methods can be a reason for diversity in a result of various studies. No correlation was found between PI, salivary lipids, proteins, and TAC with gingival health status. So, the authors suggest that in addition to further studies on these variables, the other risk factors for gingival problems in diabetic patients involve features of inflammation, immune function, neutrophil activity, and cytokine biology to be considered.

Conclusion

A higher GI was found in diabetic patients compared to healthy children, which was not related to microbial plaque accumulation. Salivary lipids and protein levels despite α-amylase in DM patients were lower than that of healthy subjects, but no difference was found between salivary lipids or protein levels in well-controlled and poorly-controlled patients. TAC of saliva was not significantly different between groups. No correlation was found between salivary lipids, proteins, and TAC with gingival health status.

References

1. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev. 1999; 15:205-218.
2. Wändell PE. Quality of life of patients with diabetes mellitus an overview of research in primary health care in the Nordic countries. Scandinavian Journal of Primary Health Care. 2005; 23:68-74.
3. Association AD. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014; 37 (Supplement 1):S81-S90.
4. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes Research and Clinical Practice. 2019; 157:107843.
5. Saini R, Saini S, Sugandha R. Periodontal disease: The sixth complication of diabetes. Journal of Family and Community Medicine. 2011; 18:31.
6. Löe H. Periodontal disease: the sixth complication of diabetes mellitus. Diabetes Care. 1993; 16:329-334.
7. Cianciola L, Park B, Bruck E, Mosovich L, Genco R. Prevalence of periodontal disease in insulin-dependent diabetes mellitus (juvenile diabetes). The Journal of the American Dental Association. 1982; 104:653-660.
8. Jenkins WM, Papapanou PN. Epidemiology of periodontal disease in children and adolescents. Periodontology 2000. 2001; 26:16-32.
9. Lalla E, Cheng B, Lal S, Tucker S, Greenberg E, Goland R, et al. Periodontal changes in children and adolescents with diabetes: a case-control study. Diabetes Care. 2006; 29:295-299.
10. Yeh CK, Christodoulides NJ, Floriano PN, Miller CS, Ebersole JL, Weigum SE, et al. Current development of saliva/oral fluid-based diagnostics. Texas Dental Journal. 2010; 127:651.
11. Ebersole JL, Nagarajan R, Akers D, Miller CS. Targeted salivary biomarkers for discrimination of periodontal health and disease (s). Frontiers in Cellular and Infection Microbiology. 2015; 5:62.
12. Syndergaard B, Al‐Sabbagh M, Kryscio RJ, Xi J, Ding X, Ebersole JL, et al. Salivary biomarkers associated with gingivitis and response to therapy. Journal of Periodontology. 2014; 85:e295-e303.
13. Wu YC, Ning L, Tu YK, Huang CP, Huang NT, Chen YF, et al. Salivary biomarker combination prediction model for the diagnosis of periodontitis in a Taiwanese population. Journal of the Formosan Medical Association. 2018; 117:841-848.
14. Casanova L, Hughes F, Preshaw P. Diabetes and periodontal disease. BDJ Team. 2015; 1:15007.
15. Lasisi T, Fasanmade A. Salivary flow and composition in diabetic and non-diabetic subjects. Niger J Physiol Sci. 2012; 27:79-82.
16. Meurman JH, Rantonen P, Pajukoski H, Sulkava R. Salivary albumin and other constituents and their relation to oral and general health in the elderly. Oral Surg Oral Med Oral Patho Oral Radio Endo. 2002; 94:432-438.
17. Navalkar A, Bhoweer A. Alterations in whole saliva constituents in patients with diabetes mellitus and periodontal disease. Journal of Indian Academy of Oral Medicine and Radiology. 2011; 23:498.
18. Baik JE, Hong SW, Choi S, Jeon JH, Park OJ, Cho K, et al. Alpha‐amylase is a human salivary protein with affinity to lipopolysaccharide of Aggregatibacter actinomycetemcomitans. Molecular Oral Microbiology. 2013; 28:142-153.
19. Ochiai A, Harada K, Hashimoto K, Shibata K, Ishiyama Y, Mitsui T, et al. α‐Amylase is a potential growth inhibitor of P orphyromonas gingivalis, a periodontal pathogenic bacterium. Journal of Periodontal Research. 2014; 49:62-68.
20. Fábián TK, Hermann P, Beck A, Fejérdy P, Fábián G. Salivary defense proteins: their network and role in innate and acquired oral immunity. International Journal of Molecular Sciences. 2012; 13:4295-4320.
21. Giannobile WV, Beikler T, Kinney JS, Ramseier CA, Morelli T, Wong DT. Saliva as a diagnostic tool for periodontal disease: current state and future directions. Periodontology 2000. 2009; 50:52.
22. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11. 2002; 246:1-190. PubMed
23. Ismail AF, McGrath CP, Yiu CK. Oral health status of children with type 1 diabetes: a comparative study. Journal of Pediatric Endocrinology and Metabolism. 2017; 30:1155-1159.
24. Babu KG, Subramaniam P, Kaje K. Assessment of dental caries and gingival status among a group of type 1 diabetes mellitus and healthy children of South India–a comparative study. Journal of Pediatric Endocrinology and Metabolism. 2018; 31:1305-1310.
25. Rewers MJ, Pillay K, De Beaufort C, Craig ME, Hanas R, Acerini CL, et al. Assessment and monitoring of glycemic control in children and adolescents with diabetes. Pediatric diabetes. 2014; 15:102-114.
26. Owlia F, Akhavan Karbassi M, Ahadian H. Comparison of salivary pH in diabetic patients referring to Diabetes Center of Shahid Sadoughi University of Medical Sciences with non-diabetic controls. SSU Journals. 2012; 20:82-89.
27. Singh S, Ramesh V, Oza N, Balamurali PD, Prashad KV, Balakrishnan P. Evaluation of serum and salivary lipid profile: A correlative study. Journal of Oral and Maxillofacial Pathology, JOMFP. 2014; 18:4.
28. Jafari A, Pouramir M, Shirzad A, Motallebnejad M, Bijani A, Moudi S, et al. Evaluation of salivary alpha amylase as a biomarker for dental anxiety. Iran J Psychiatry Behav Sci. 2018; 12:e9350.
29. Arash VA, Mahjoub S, Haj Ahmadi M, Padganeh T. Amounts of salivary total protein before and after orthodontic tooth movement. Journal of Babol University of Medical Sciences (JBUMS). 2008; 10:43.
30. Lubran MM. The measurement of total serum proteins by the Biuret method. Annals of Clinical & Laboratory Science. 1978; 8:106-110.
31. Apak Ra, Özyürek M, Güçlü K, Çapanoğlu E. Antioxidant activity/capacity measurement. 1. Classification, physicochemical principles, mechanisms, and electron transfer (ET)-based assays.. Journal of Agricultural and Food Chemistry.. 2016; 64:997-1027.
32. Alam MN, Bristi NJ, Rafiquzzaman M. Review on in v-ivo and in vitro methods evaluation of antioxidant activity. Saudi Pharmaceutical Journal. 2013; 21:143-152.
33. Löe H. The gingival index, the plaque index and the retention index systems. The Journal of Periodontology. 1967; 38:610-616.
34. Alves C, Menezes R, Brandão M. Salivary flow and dental caries in Brazilian youth with type 1 diabetes m-ellitus. Indian Journal Dental Research. 2012; 23:758.
35. Machado D, Coelho A, Paula A, Caramelo F, Carrilho F, Barros L, et al. Prevalence of dental caries in patients with type 1 diabetes mellitus treated with multiple insulin injections and that of individuals without diabetes. Acta Médica Portuguesa. 2017; 30:402-408.
36. Daković D, Mileusnić I, Hajduković Z, Čakić S, Hadži-Mihajlović M. Gingivitis and periodontitis in children and adolescents suffering from type 1 diabetes mellitus. Vojnosanitetski Pregled. 2015; 72:265-273.
37. Sanz M, Ceriello A, Buysschaert M, Chapple I, Demmer RT, Graziani F, et al. Scientific evidence on the links between periodontal diseases and diabetes: consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the international diabetes federation and the European Federation of Periodontology. Diabetes Research and Clinical Practice. 2018; 137:231-241.
38. Buczko P, Zalewska A, Szarmach I. Saliva and oxidative stress in oral cavity and in some systemic disorders. J Physiol Pharmacol. 2015; 66:1-7.
39. Sadeghi R, Taleghani F, Mohammadi S, Zohri Z. The effect of diabetes mellitus type I on periodontal and dental status. Journal of Clinical and Diagnostic Research, JCDR. 2017; 11:ZC14.
40. Subramaniam P, Sharma A, Kaje K. Association of salivary triglycerides and cholesterol with dental caries in children with type 1 diabetes mellitus. Special Care in Dentistry. 2015; 35:120-122.
41. Lakshmi PD, Sridevi E, Sankar AS, Kumar MM, Sridhar M, Sujatha B. Diagnostic perspective of saliva in insulin dependent diabetes mellitus children: an in vivo study. Contemporary Clinical Dentistry. 2015; 6:443.
42. Panchbhai AS, Degwekar SS, Bhowte RR. Estimation of salivary glucose, salivary amylase, salivary total protein and salivary flow rate in diabetics in India. Journal of Oral Science. 2010; 52:359-368.
43. Basir L, Aminzade M, Javid AZ, Khanehmasiedi M, Rezaeifar K. Oral health and characteristics of saliva in diabetic and healthy children. Australasian Medical Journal (Online). 2017; 10:884-889.
44. Astaneie F, Afshari M, Mojtahedi A, Mostafalou S, Zamani MJ, Larijani B, et al. Total antioxidant capacity and levels of epidermal growth factor and nitric oxide in blood and saliva of insulin-dependent diabetic patients. Archives of Medical Research. 2005; 36:376-81.
45. Gümüş P, Buduneli N, Çetinkalp Ş, Hawkins SI, Renaud D, Kinane DF, et al. Salivary antioxidants in patients with type 1 or 2 diabetes and inflammatory periodontal disease: a case‐control study. Journal of Periodontology. 2009; 80:1440-1446.
46. Rai K, Hegde A, Kamath A, Shetty S. Dental caries and salivary alterations in Type I Diabetes. Journal of Clinical Pediatric Dentistry. 2011; 36:181-184.
47. Aral CA, Nalbantoğlu Ö, Nur BG, Altunsoy M, Aral K. Metabolic control and periodontal treatment decreases elevated oxidative stress in the early phases of type 1 diabetes onset. Archives of Oral Bbiology. 2017; 82:115-120.
48. Reznick AZ, Shehadeh N, Shafir Y, Nagler RM. Free radicals related effects and antioxidants in saliva and serum of adolescents with Type 1 diabetes mellitus. Archives of Oral Bbiology. 2006; 51:640-648.