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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 220-224

Gingival crevicular blood: A noninvasive pathway to determine blood glucose level in periodontal patients


1 Department of Periodontics, North Bengal Dental College and Hospital, Darjeeling, West Bengal, India
2 Department of Periodontics, Guru Nanak Institute of Dental Science and Research, Kolkata, West Bengal, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Sohini Banerjee
83/2, B.P. Lane, Kolkata - 700 035, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_88_17

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  Abstract 

Aim: The aim of this study is to determine the efficacy and reliability of estimation of blood glucose level of patients with diabetes suffering from periodontal disease using gingival crevicular blood through periodontal pockets. Materials and Methods: A total of 70 patients with a known history of diabetes mellitus suffering from chronic periodontal diseases having visible signs of gingival inflammation were selected for the study based on other inclusion criteria. The excess gingival crevicular blood produced during routine periodontal examinations were carefully collected onto the glucometer test strips, and blood glucose levels were estimated with the help of glucose self-monitoring device (Glucometer). The finger-prick blood samples were also collected and glucose levels were also estimated using Glucometer. Patient's venous blood samples were collected at the same time, and blood glucose estimations were done using conventional laboratory measurements. Results: The results of this study revealed a strong correlation between (a) the gingival crevicular blood glucose (GCBG) and finger-prick blood glucose (Pearson's correlation r = 0.982; P < 0.001); and also (b) between GCBG and corrected venous blood glucose (Pearson's correlation r = 0.891; P < 0.001). Conclusion: Oozing blood from the gingival crevice during the routine periodontal examination can be used as a quick, noninvasive, chair-side diagnostic mode to estimate, and/or monitor blood glucose levels in periodontal patient suffering from diabetes mellitus with the help of Glucometer.

Keywords: Diabetes mellitus, gingival crevicular blood, periodontal disease


How to cite this article:
Banerjee S, Ganguly R, Pal TK. Gingival crevicular blood: A noninvasive pathway to determine blood glucose level in periodontal patients. Indian J Dent Sci 2017;9:220-4

How to cite this URL:
Banerjee S, Ganguly R, Pal TK. Gingival crevicular blood: A noninvasive pathway to determine blood glucose level in periodontal patients. Indian J Dent Sci [serial online] 2017 [cited 2017 Dec 17];9:220-4. Available from: http://www.ijds.in/text.asp?2017/9/4/220/219635


  Introduction Top


Diabetes mellitus is clinically and genetically heterogeneous group of disorders affecting the metabolites of carbohydrates and proteins, and resulting from defects in insulin secretion, action, or both.[1],[2],[3],[4] Periodontal disease is now considered to be the sixth complication of diabetes mellitus and diabetes act as a major risk factor for it.[5] However, globally, the prevalence of diabetes is predicted to be double from 171 million in 2000 to 366 million in 2030 with a maximum increase in India. It is predicted that by 2030 diabetes mellitus may afflict up to 79.4 million individuals in India.[6] Diabetes is fast gaining the status of a potential epidemic in India with >62 million individuals with diabetes currently diagnosed with the disease.[6] However, most of these cases usually remain undetected at early stage increasing the potential complications of diabetes mellitus in later stages.[2],[6],[7]

Since the dental clinicians are often encountered with patients with diabetes in day-to-day practice, a noninvasive manner of blood glucose estimations are often necessary in routine dental practice. Although various blood glucose estimation test are available such as conventional laboratory blood glucose estimation, glycated hemoglobin estimation, and oral glucose tolerance test, most of them are complex, time taking, and invasive procedures.[2],[4],[8],[9] Hence, the screening for diabetes in the dental office is usually accomplished through analysis of patient's history, symptoms, and the conventional laboratory methods that may not reflect their current blood glucose status.[2] Therefore, there is a need of a quick, chair-side, noninvasive diagnostic mode to determine blood glucose levels in periodontal patient suffering from diabetes mellitus in dental practice.

Periodontal diseases often produce considerable amount of extravasated blood during routine periodontal examination while probing through the diseases gingival tissue.[2],[4],[8],[9],[10] This crevicular blood oozed during periodontal probing might be an excellent source of blood for glucometric analysis using the self-monitoring glucose device (Glucometer) instead of conventional venous blood glucose.[8],[9],[10] It could also be used for screening of diabetes mellitus in suspected population. Therefore, a study has been designed with the consideration of all three types of blood sources, that is, gingival crevicular blood, finger-prick blood, venous blood to find the applicability, reliability, and efficacy of gingival crevicular blood in glucose estimation with the use of Glucometer compared to other available methods such as finger prick and venous blood glucose estimation. Therefore, the aim of the study would be as follows:

  1. To find a noninvasive pathway for determining/monitoring blood glucose in patient with diabetes suffering from periodontitis
  2. To test feasibility of gingival crevicular blood in estimating the blood glucose compared to finger prick and venous blood glucose method
  3. To screen the unsuspected periodontal population for the presence of diabetes in a noninvasive manner in clinical practice.



  Materials and Methods Top


This study had been conducted after obtaining ethical clearance from the Institution's Ethics Committee, and the procedure was performed as per the ethical regulations and guidelines of Declaration of Helsinki. All the patients were initially explained about the procedure, and informed consent was obtained from the participants. A total of 70 patients with known history of diabetes mellitus suffering from chronic periodontal diseases having the following criteria were selected for the study:

  1. Patients with age group of 35–65 years
  2. Currently suffering from periodontal diseases with the visible signs of gingival inflammation
  3. Patients without any history of bleeding disorder
  4. Patients recently not having antibiotic prophylaxis
  5. Patients currently not taking any anticoagulants
  6. Patients with no history of intake of substances that interfere with coagulation system.


Three different sources of blood (gingival crevicular blood, finger-prick blood, and venous blood) were collected for the study. Upper anterior teeth having visible signs of gingival inflammation were selected. The area was carefully isolated, and the periodontal probe was inserted into the desired area to determine the periodontal status [Figure 1]. Gingival blood oozed out from the periodontal pocket was then carefully collected on glucometer test strips, and the estimation was done with the help of Glucometer [Figure 2]. At the same time, finger-prick blood was collected from the soft tissue of the nondominant hand and level of glucose was measured with the help of Glucometer [Figure 3]. The intravenous blood of the patients was also collected and sent to the laboratory for random blood glucose and hematocrit (Hct) estimation. Hct or packed cell volume is the percentage of blood volume occupied by the red blood cells.[2] This measurement was important because the Glucometer is usually measured whole blood glucose, whereas most of the laboratory measures serum blood glucose. Therefore, conventional laboratory blood glucose measurement would be converted to whole blood glucose measurement after correcting the Hct [2],[5] using the following method:
Figure 1: Periodontal probing was done to assess the periodontal tissue status

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Figure 2: Gingival crevicular blood glucose was estimated with Glucometer

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Figure 3: Finger-prick blood glucose was estimated with Glucometer

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Hct corrected venous glucose (mg/dl) = laboratory mg/dl × [1.0− (0.0024 × Hct)]

The physiological drop in the blood glucose concentration was usually observed as it was passed from a capillary (such as gingival crevice) area into a venous area due to normal cellular glucose uptake. The drop is 2–5 mg/dl or an average of 3.5 mg/dl for an individual.[2] The measurements for direct comparison between laboratory glucose values and glucometer readings [2] was finally done using the following formula:

Corrected venous glucose (mg/dl) = Laboratory mg/dl × [1.0 − (0.0024 × Hct)] + 3.5 mg/dl


  Results and Observation Top


The values of gingival crevicular blood glucose (GCBG) were found to be in the range of 47 mg/dl to 364 mg/dl. The values of finger-prick blood glucose (FPBG) were found to be in range of 96 mg/dl to 393 mg/dl. The values of corrected venous blood glucose (CVBG) were found to be within the range of 83.92 mg/dl to 316.42 mg/dl. The data were then subjected to statistical analysis. The mean values of blood glucose from all the three sources along with standard deviations were summarized in [Table 1]. The Pearson's correlation values between the three different blood glucose sources along with the other statistical parameters were summarized in [Table 2]. The results of this study revealed a strong correlation (Pearson's correlation r = 0.982; P < 0.001) between the GCBG and FPBG and also a strong correlation (Pearson's correlation r = 0.891; P < 0.001) between GCBG and CVBG. A strong correlation (Pearson's correlation r = 0.925; P < 0.001) was also established between FPBG and CVBG. The mean comparison of glucose values along with the scatter diagrams among the three parameters were summarized in the [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Table 1: Mean values of all three different sources of blood glucose along with standard deviations

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Table 2: Pearson's correlation values of all three different parameters along with P level

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Figure 4: Comparison of mean values of gingival crevicular blood glucose and finger-prick blood glucose

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Figure 5: Scatter diagram depicting the relationship between gingival crevicular blood glucose and finger-prick blood glucose

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Figure 6: Comparison of mean values between gingival crevicular blood glucose and corrected venous blood glucose

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Figure 7: Scatter diagram depicting the relationship between gingival crevicular blood glucose and corrected venous blood glucose

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Figure 8: Scatter diagram depicting the relationship between finger-prick blood glucose and corrected venous blood glucose

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  Discussion Top


Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, action, and/or both.[1],[2],[3] Periodontal disease is now considered to be a sixth complications of diabetes mellitus and also proved to have a bidirectional relationship.[3],[5] Diabetes mellitus now has become a major burden on the all health-care facilities throughout the world. According to the WHO, an estimated 347 million people in the world had diabetes in 2008, and India had 69.2 million people living with diabetes (8.7%) as per the 2015 data. Of these, it remained undiagnosed in >36 million people.[6] The WHO report stated that the diabetes epidemic is rapidly increasing in many countries, with the documented increase most dramatic in low- and middle-income countries.[1],[6] Hence, in the view of growing number of people with undiagnosed diabetes and the increased risk for periodontal patients, diabetes screening at the time of periodontal visit often seems to offer a promising approach.

Periodontal diseases are the chronic inflammatory diseases of the supporting periodontal tissues resulting in tooth loss. Periodontal inflammation with or without the complicating factor of diabetes mellitus is known to produce ample extravasated blood during diagnostic procedures.[2],[4],[8],[9],[10],[11],[12] This excess amount of crevicular blood oozed during periodontal diagnostic procedure might be used as an excellent, alternative, chair-side, and noninvasive source of blood glucose estimation using Glucometer in periodontal patients. It could also be used for screening of diabetes mellitus in suspected population having periodontal disease. Although conventional laboratory blood glucose measurement is still considered to be the gold standard in diagnosing the diabetes mellitus or determining the blood glucose status, self-monitoring glucose device (Glucometer) often provides a rapid, chair-side, less traumatic mode of determining blood glucose status in the patients.[2],[4],[8],[9],[10],[11],[12] Therefore, this study has been designed with the consideration of all three blood glucose sources (gingival crevicular blood, finger-prick blood, and venous blood) to find the easy, quick, noninvasive, chair-side mode of diagnostic pathway to determine and/or monitor the blood glucose level in periodontal patients and also to find its efficacy, reliability, and validity in estimating the blood glucose compared to other methods.

Several investigators and researchers suggested that gingival crevicular blood could be used as an easily acceptable, noninvasive source for blood glucose estimation in diabetic population suffering from periodontitis.[2],[4],[8],[9],[10],[11],[13],[14] Estimations of GCBG levels were previously conducted and showed positive correlations with capillary blood glucose levels, suggesting that the crevicular blood oozing out from the crevice during routine periodontal examinations might be a valuable mode in identifying the potential patients with diabetes.[2],[4],[8],[9],[10],[11] However, several investigators proposed different methods of collections of crevicular blood samples such as micropipettes, blunted insulin syringe to reduce the contamination with the saliva, and/or other oral tissue fluids.[2],[4],[8] Stein and Nebbia were among the first to describe a chair-side method of diabetic screening with gingival blood and had used the interdental gingival papilla prick method with test strips to screen the patients with high gingival blood glucose.[14] Some investigator suggested the rubbing of blood onto the test strip from a blood-laden dental curette.[15] Rubbing or direct wiping of intraoral blood onto the test strip will not produce a uniformly timed reaction and may damage the strip's chemical indicator surface.[16] However, significant contamination may occur from saliva, oral debris, and plaque on the dental curette from its entry into the gingival sulcus.[15] Beikler et al. suggested direct use of test strip of glucometer to collect blood sample from gingiva.[17] However, most of the investigators suggested the use of the crevicular oozing blood from the gingival crevice during routine periodontal examinations for glucose estimations.[2],[4],[9],[10],[13] However, other studies have failed to provide the evidence regarding the use of gingival crevicular blood for estimating blood glucose during the routine periodontal examination.[18] However, most of the recently developed glucometer devices require very small amount of blood (2–3 μl blood as low as 1 μl), and the results were usually obtained within 5 s.[2],[4] Hence, Glucometer could be used for monitoring the blood glucose during treatment or as a screening tool, but confirmation should only be based on venous plasma glucose estimation in the laboratory.[10],[12] ADA recommended that the prediction error of blood glucose monitoring devices falls within 15% of laboratory standard; however, clinically, analytic precision to 20% is considered acceptable.[2],[4] Since most of the laboratory measures serum blood glucose, conventional laboratory blood glucose measurement was converted to whole blood glucose measurement after correcting the Hct in this study.[2] Natural, physiologic drop in blood glucose was also considered in the present study in considerations with the previous one.[2]

In this study, patients having a known history of diabetes mellitus with visible signs of gingival inflammation were only selected so that ample sample would be available during the examination and the results showed positive correlations between the parameters such as Pearson's correlation r = 0.982; P < 0.001 between the GCBG and FPBG and the Pearson's correlation r = 0.891; P < 0.001 between GCBG and CVBG. Therefore, the GCBG estimation through Glucometer in periodontal patients might be used as a valuable, essential, chair-side, noninvasive, diagnostic tool to determine, and/or monitor blood glucose level in periodontal patients. However, more studies would be required in the near future to find its applicability in clinical practice.


  Conclusion Top


With the alarming rise of diabetes mellitus as global epidemic disease and its association with periodontal disease and other systemic complications, GCBG estimation through Glucometer could be used as a reliable, effective. Noninvasive, chair-side mode of estimating, monitoring, and/or screening diabetes mellitus in periodontal populations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Ann Periodontol 2001;6:99-112.  Back to cited text no. 3
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Rajesh KS, Irshana R, Arun Kumar MS, Hegde S. Effectiveness of glucometer in screening diabetes mellitus using gingival crevicular blood. Contemp Clin Dent 2016;7:182-5.  Back to cited text no. 4
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Narula HK, Narula JS, Bharti V, Gupta H. In office gingival crevicular blood glucose monitoring in diabetic patients. J Periodontal Med Clin Pract 2014;1:29-37.  Back to cited text no. 8
    
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Stein GM, Nebbia AA. A chairside method of diabetic screening with gingival blood. Oral Surg Oral Med Oral Pathol 1969;27:607-12.  Back to cited text no. 14
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    Figures

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