Periodontal conditions in insulin-dependent diabetes mellitus

Pathophysiological relationships between periodontitis and systemic disease: recent concepts involving serum lipids

Periodontitis has been traditionally regarded as a chronic inflammatory oral infection. However, recent studies indicate that this oral disease may have profound effects on systemic health. The search for cellular/molecular mechanisms linking periodontitis to changes in systemic health and systemic physiology has resulted in the evolution of a new area of lipid research establishing linkages between existing multidisciplinary biomedical literature, recent observations concerning the effects of serum lipids on immune cell phenotype/function, and a heightened interest in systemic responses to chronic localized infections. There appears to be more than a casual relationship between serum lipid levels and systemic health (particularly cardiovascular disease, diabetes, tissue repair capacity, and immune cell function), susceptibility to periodontitis, and serum levels of pro-inflammatory cytokines. In terms of the potential relationship between periodontitis and systemic disease, it is possible that periodontitis-induced changes in immune cell function cause metabolic dysregulation of lipid metabolism through mechanisms involving proinflammatory cytokines. Sustained elevations of serum lipids and/or pro-inflammatory cytokines may have a serious negative impact on systemic health. The purpose of this paper is to present the background, supporting data, and hypotheses related to this concept. As active participants in this emerging and exciting area of investigation, we hope to stimulate interest and awareness among biomedical scientists and practitioners.

Diabetes and periodontal diseases. Committee on Research, Science and Therapy. American Academy of Periodontology

This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office.

Heightened gingival inflammation and attachment loss in type 2 diabetics with hyperlipidemia

BACKGROUND

Our previous studies in diabetic (DB) rats suggest that hyperlipidemia may cause a dysregulation of the cellular and local cytokine response to periodontitis (AP). The objective of the present study was to determine if diabetes has a similar dysregulatory effect on the gingival response to AP in humans.

METHODS

Peripheral blood, as well as gingival tissue (GT) and gingival crevicular fluid (GCF), was obtained from a total of 35 patients who were categorized into the following groups based on level of diabetic (type 2) control and presence or absence of adult periodontitis (AP): group 1, systemically and periodontally healthy (n = 6); group 2, systemically healthy with adult periodontitis (n = 7); group 3, well-controlled diabetes and periodontally healthy (n = 6); group 4, well-controlled diabetes with adult periodontitis (n = 5); group 5, poorly controlled diabetes and periodontally healthy (n = 5); group 6, poorly controlled diabetes and adult periodontitis (n = 6). All subjects were given a thorough periodontal examination, including probing depths (PD), clinical attachment levels (CAL), gingival index (GI), plaque index (PI), and vertical bitewing radiographs. Blood studies included levels of glycated hemoglobin (HbA1c), triglycerides (TG), cholesterol (CHL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). The levels of interleukin-1 beta (IL-1beta) in GCF and GT, interleukin-6 (IL-6), and platelet-derived growth factor AB (PDGF-AB) in GT from patients in each experimental group were analyzed by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Our results indicate that all clinical indices except PI were significantly elevated in the poorly controlled and well-controlled diabetics, compared to systemically healthy patients, but only in the subjects without preexisiting AP (Tukey's multiple comparisons, P <0.05). Pairwise linear regression analysis revealed significant (P <0.01) positive associations between periodontal inflammation (PD, CAL, PI, GI) and levels of GCF IL-1beta, GT IL- 1beta GT IL-6, but not GT PDGF; moreover, GT IL-6 levels were significantly associated (P<0.05) with GT IL-1beta. As TG levels increased in the non-AP patients (group 1 < group 3 < group 5), there was a trend, not significant, for increased GCF IL-1beta levels and increased gingival inflammation. Interestingly, periodontitis resulted in increased PDGF-AB levels in the gingiva of systemically healthy and well-controlled diabetes patients, but this increase was obtunded in poorly controlled diabetes patients.

CONCLUSIONS

This confirms our earlier work in the diabetic rat model. These studies indicate that decreased metabolic control in type 2 diabetics results in increased serum triglycerides and has a negative influence on all clinical measures of periodontal health, particularly in patients without preexisting periodontitis. Levels of the cytokine IL- 1beta showed a trend for increasing as diabetic control diminished. In contrast, levels of the growth factor PDGF, which normally increase in periodontitis, decreased in poorly controlled diabetics with periodontitis. These studies suggest a possible dysregulation of the normal cytokine/growth factor signaling axis in poorly controlled type 2 diabetics that may contribute to periodontal breakdown/diminished repair.

Diabetes and periodontal diseases

This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office.

Evidence-based care in orthodontics and periodontics: a review of the literature

BACKGROUND

In this article, the author reviews the evidence-based literature in the fields of periodontics and orthodontics to clarify the relationship between orthodontic tooth movement and various types of common periodontal disorders.

TYPES OF STUDIES REVIEWED

The first section is a review of the literature on common periodontal disorders. The second is a review of evidence-based studies in the combined fields of orthodontics and periodontics, with a focus on orthodontic treatment possibilities, limitations and risks inherent in patients with periodontal disorders, particularly active periodontal disease.

RESULTS

The literature on orthodontic tooth movement as it relates to periodontal disease shows that proper orthodontic treatment in patients with excellent oral hygiene and the absence of significant periodontal disorders should not pose any significant periodontal risk. In the presence of poor oral hygiene, however, and under circumstances of certain types of periodontal disorders, fixed orthodontic appliances and tooth movement can contribute to significant deleterious periodontal consequences.

CLINICAL IMPLICATIONS

This review provides a clear understanding of what is known about orthodontic treatment possibilities, limitations and inherent risks in patients who may have certain types of periodontal disorders. It also underscores the importance of teamwork among the restorative dentist, periodontist and orthodontist when planning treatment for these patients. The author also offers a specific patient management protocol for this interdisciplinary dental team to follow.

Periodontitis and anti-neutrophil cytoplasmic antibodies in systemic lupus erythematosus and rheumatoid arthritis: a comparative study

BACKGROUND

This investigation was designed to determine and compare the distribution pattern of anti-neutrophil cytoplasmic antibodies (ANCA) in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in the presence or absence of periodontal disease.

METHODS

Sera of 30 patients with SLE and 30 with RA were tested for ANCA utilizing an indirect enzyme immunosorbent assay (ELISA) directed to a neutrophil granular extract and 6 neutrophil granule proteins. A control group of 20 healthy individuals showing neither evidence of periodontal disease nor systemic compromise was also included in this study.

RESULTS

For RA, the number of ANCA-positive sera was very low but was evenly distributed among patients with and without periodontitis. Conversely, a high number of ANCA-positive sera in SLE was found mostly in individuals presenting periodontal compromise. A statistically significant association between ANCA and periodontitis in SLE patients was found (P <0.005, chi square test).

CONCLUSIONS

A marked difference in the number and distribution of ANCA with respect to periodontitis between RA and SLE was found. Hyperresponsiveness of B cells and polyclonal B activation to periodontopathic bacteria in SLE might be accountable for the high numbers of ANCA and the close association observed between those autoantibodies and periodontitis in SLE.

Glycemic control and alveolar bone loss progression in type 2 diabetes

This study tested the hypothesis that the risk for alveolar bone loss is greater, and bone loss progression more severe, for subjects with poorly controlled (PC) type 2 diabetes mellitus (type 2 DM) compared to those without type 2 DM or with better controlled (BC) type 2 DM. The PC group had glycosylated hemoglobin (HbA1) > or = 9%; the BC group had HbA1 < 9%. Data from the longitudinal study of the oral health of residents of the Gila River Indian Community were analyzed. Of the 359 subjects, aged 15 to 57 with less than 25% radiographic bone loss at baseline, 338 did not have type 2 DM, 14 were BC, and 7 were PC. Panoramic radiographs were used to assess interproximal bone level. Bone scores (scale 0-4) corresponding to bone loss of 0%, 1% to 24%, 25% to 49%, 50% to 74%, or > or = 75% were used to identify the worst bone score (WBS) in the dentition. Change in worst bone score at follow-up, the outcome, was specified on a 4-category ordinal scale as no change, or a 1-, 2-, 3-, or 4-category increase over baseline WBS (WBS1). Poorly controlled diabetes, age, calculus, time to follow-up examination, and WBS1 were statistically significant explanatory variables in ordinal logistic regression models. Poorly controlled type 2 DM was positively associated with greater risk for a change in bone score (compared to subjects without type 2 DM) when the covariates were included in the model. The cumulative odds ratio (COR) at each threshold of the ordered response was 11.4 (95% CI = 2.5, 53.3). When contrasted with subjects with BC type 2 DM, the COR for those in the PC group was 5.3 (95% CI = 0.8, 53.3). The COR for subjects with BC type 2 DM was 2.2 (95% CI = 0.7, 6.5), when contrasted to those without type 2 DM. These results suggest that poorer glycemic control leads to both an increased risk for alveolar bone loss and more severe progression over those without type 2 DM, and that there may be a gradient, with the risk for bone loss progression for those with better controlled type 2 DM intermediate to the other 2 groups.

Epidemiological and clinical aspects of periodontal diseases in diabetics

The association between diabetes mellitus and periodontal disease has long been discussed, with conflicting conclusions. On the one hand, numerous reports indicate a high prevalence of periodontal disease in diabetics compared to healthy controls, while others fail to show such a relationship. Clarification of this dilemma has been occurring as the diagnostic criteria for periodontal disease destruction improve and the number and size of the populations surveyed grow. This review is based on a selective review of the literature from the present decade. To date, based mainly on an extensive study of the Pima Indians who have an extremely high incidence of non-insulin-dependent diabetes mellitus (NIDDM), it seems to be clear that patients with NIDDM have a higher prevalence and severity of periodontal disease destruction than non-diabetics in the same population. However, it must be borne in mind that these data are for a special population. Studies on patients with insulin-dependent diabetes mellitus (IDDM) indicate results similar to those found in studies on NIDDM. There is an increase in prevalence and severity of periodontitis compared to controls. For both IDDM and NIDDM, there does not appear to be any correlation between the prevalence or the severity of periodontal disease and the duration of diabetes. Well-controlled diabetic patients as measured by blood glycated hemoglobin levels have less severe periodontal disease than poorly controlled diabetics. The principles of treatment of periodontitis in diabetics are the same as those for non-diabetic patients and are consistent with our approach to all high-risk patients who have already developed periodontal disease. The major efforts should be directed at the prevention of periodontitis in patients at risk of developing diabetes. Another important clinical question relates to the influence of periodontal disease on the control of the diabetic state. Here again the literature is unclear; however, a recent development suggests that effective control of periodontal infection in patients with diabetes reduces the level of advanced glycosylation end products in the serum. If future studies can confirm this effect, then periodontal infection control must be considered an integral part of diabetic control.

Healing response to non-surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological, and immunologic results

The aim of the present study was to monitor clinical, microbiological, medical, and immunological effects of non-surgical periodontal therapy in diabetics and healthy controls. 20 IDDM (insulin dependent, n = 7) or NIDDM (non-insulin dependent, n = 13) diabetic patients (median duration 11.5 years, range of HbA1C: 4.4-10.6%) with moderate to advanced periodontal disease and 20 matched healthy control patients, were subjected to supragingival pretreatment and subsequent subgingival therapy. Periodontal examinations (API, PBI, BOP, PPD, PAL), microbiological examinations (culture), medical routine examinations, and immunological examinations (oxidative burst response of PMNs to TNF-alpha and FMLP) were performed at baseline, 2 weeks after supragingival, and 4 months after subgingival therapy. 4 months after completion of non-surgical therapy, the following compared to baseline significant (p < or = 0.05) changes (delta) of clinical parameters (median) were found in diabetic patients versus control patients: deltaAPI (30.4% versus 36.3%), deltaPBI (22.9% versus 24.2%), deltaBOP (39.5% versus 46.9%). The median % per patient of pockets with PPD > or = 4 mm decreased from 41.9% to 28.3% in diabetics, and from 41.6% to 31.8% in controls. Microbiologically, similar reductions of periopathogenic bacteria were found in diabetics and controls. Neither periodontal data nor the oxidative burst response of PMNs showed any significant difference (p > 0.05) between diabetics and control patients. In this study, periodontal therapy had no significant influence on medical data of diabetics. In conclusion, this study indicates that metabolically well-controlled diabetics might respond to non-surgical periodontal therapy as well as healthy control patients.

Diabetes prevents periodontitis-induced increases in gingival platelet derived growth factor-B and interleukin 1-beta in a rat model

Periodontitis is a chronic inflammatory disease characterized by a progression that is very much dependent on host response. The gingiva can be considered to be in a constant state of wounding (pathologic wounding by bacterial plaque) and a constant state of maintenance/repair. In this context, any metabolic disturbance in the host which compromises tissue repair/wound healing will exacerbate the progression of periodontitis. Diabetes presents an interesting example because two major complications of diabetes are delayed wound healing and periodontitis. Our previous studies indicate that delayed wound healing and periodontitis may be manifestations of a general systemic deficit in diabetes involving alteration of macrophage cytokine gene expression. The present study was designed to determine whether: 1) diabetes-induced metabolic alterations affect gingival cytokine levels; and 2) diabetes-induced metabolic alterations modify the gingival cytokine profile in periodontitis. Sprague-Dawley rats (N=12/group) were injected with streptozotocin (65 mg/kg) into the tail vein to induce diabetes (defined by blood glucose levels > 250 mg/dl) or received the injection vehicle or no treatment as controls. Periodontitis was induced in additional groups of diabetic and control rats by gavage with Porphyromonas gingivalis A7436. After 90 days, serum glucose was analyzed to document diabetes; alveolar bone level was measured to document severity of periodontitis; gingiva was harvested circumferentially from the first and second molars; and cytokines in gingival homogenates were assayed by ELISA using commercial kits. Cytokine levels were expressed as mean+/-SEM pg/microg protein. Diabetes alone did not alter the gingival cytokine profile for platelet-derived growth factor B (PDGF-B), interleukin 1-beta (IL-1beta), transforming growth factor-beta (TGF-beta), and tumor necrosis factor-alpha (TNF-alpha). Periodontitis alone demonstrated a significant increase (P < 0.05) in levels of PDGF-B and IL-1beta. Diabetes superimposed on periodontitis prevented these increases. Thus, diabetes-induced metabolic alterations do not affect gingival cytokine levels per se; however, they do alter the normal host response to periodontitis through blockage of periodontitis-induced increases in PDGF-B and IL-1beta.

Morphometric analysis of cellular and vascular changes in gingival connective tissue in long-term insulin-dependent diabetes

This study examined cellular and vascular changes in gingival connective tissue samples by stereologic point-counting procedures and interactive digital analyzing systems in long-term insulin-dependent diabetes mellitus patients. Gingival connective tissue capillaries representing a clinically healthy sulcus with no evidence of periodontal disease at the site of biopsy were studied in 29 patients with diabetes. Based upon their long-term medical records, 19 were identified as having poorly controlled (PIDD) and 10 as controlled insulin-dependent diabetes mellitus (CIDD). Ten nondiabetic, age- and gender-matched individuals served as controls. Thirty-nine biopsies were processed for light microscopy, and the blood vessel area was analyzed using an interactive digital analyzing system; 9 gingival biopsies, 5 diabetic and 4 controls, were processed for morphometric electron microscopic analysis. For each individual, site-specific recordings were made for the plaque index, bleeding index, probing depth, loss of attachment, and radiographic loss of interproximal alveolar bone. No evident signs of periodontitis occurred at the biopsy sites. For each PIDD patient, respective volumetric and numeric densities of cellular components including fibroblasts, neutrophilic granulocytes, monocyte/macrophages, mast cells, lymphocytes, blast cells, and plasma cells were recorded in the inflamed connective tissue (ICT). Non-cellular components such as collagen fibers and blood vessels were also recorded. PIDD patients had elevated plasma cell levels relative to controls and they appeared also to have a decreased collagen fiber density. In addition, fibroblasts occupied less volume in the ICT of PIDD patients than in controls. PIDD patients had the largest mean area of cross-section of the blood vessels, but this difference was not statistically significant (P > or = 0.211; t-test). No specific characteristics of ICT or vascular changes were detectable in adult well-controlled long-term diabetics under similar plaque conditions. Swollen and proliferated endothelial cells were frequently found in PIDD patients and the mean distance from the lumen to the outer border of basement membrane was greater in the PIDD than in the controls (P < 0.001; t-test). Overall, our findings that cellular, vascular, and connective tissue changes indicative of increased catabolism rather than anabolism detected in gingiva are especially associated with poorly controlled long-term insulin-dependent diabetes.

Specific issues in clinical trials on the use of barrier membranes in periodontal regeneration

There are presently a number of different barriers available for use clinically in guided tissue regeneration (GTR) procedures. A number of trials using these techniques and comparing different types of barrier membranes are being published in the scientific literature. This review discusses issues related to clinical trials on the use of barrier membranes in periodontal regeneration. Outcome measures, both clinical and histological, are discussed in relation to results following GTR procedures. The difference between regeneration and repair is reviewed as well as methods of clinical and histologic assessment of both these outcomes. Data regarding the impact of patient variables and tooth or defect variables on outcomes are presented and suggestions for study designs are made based on these variables. Aspects of assessing for an appropriate sample size in superiority and equivalency trials using GTR techniques are presented as well as interpretation of results following these trials and their clinical significance.

The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus

Gingival health (bleeding on probing) and oral hygiene (plaque percent) were assessed in 2 groups of children and adolescents with insulin-dependent diabetes mellitus (IDDM). 1st study group included 12 newly diagnosed diabetic children and adolescents (age range 6.3-14.0 years, 5 boys and 7 girls). They were examined on the 3rd day after initial hospital admission and at 2 weeks and 6 weeks after initiation of insulin treatment. Gingival bleeding decreased after 2 weeks of insulin treatment (37.8% versus 19.0%, p < 0.001, paired t-test), and remained at the same level when examined 1 month later while glucose balance was excellent. Another group (n = 80) of insulin-dependent diabetic children and adolescents (age range 11.7-18.4 years, 44 boys and 36 girls) with a mean duration of diabetes 6.0 years (range 0.3-15.0 years) were examined 2x at 3-month intervals. Subjects with poor blood glucose control (glycosylated haemoglobin, HbA1, values over 13%) had more gingival bleeding (46.3% on examination 1, 41.7% on examination 2) than subjects with HbA1 values less than 10% (mean gingival bleeding 35.2% and 26.9%, respectively) or subjects with HbA1 values between 10 to 13% (mean gingival bleeding 35.6% and 33.4%, respectively). Differences were significant on both examinations (p < 0.05, Anova), and remained significant after controlling the groups for differences in age, age at the onset of diabetes, duration of diabetes and pubertal stage (Ancova). Results were not related to differences or changes in dental plaque status, supporting the concept that imbalance of glucose metabolism associated with diabetes predisposes to gingival inflammation. An increase in gingival bleeding in association with hyperglycaemia suggests that hyperglycaemia-associated biological alterations, which lower host resistance toward plaque, have apparently taken place. Consequently, although not all gingivitis proceeds into a destructive periodontal disease, prevention of plaque-induced gingival inflammation should be emphasised, particularly in children and adolescents with poorly controlled diabetes.

Periodontal status of diabetic and non-diabetic men: effects of smoking, glycemic control, and socioeconomic factors

Periodontal disease is more prevalent and more severe in diabetic than in non-diabetic individuals but the magnitude of this increase is still being debated. This prospective, cross-sectional study compared the periodontal status of 118 diabetic men and 115 age-matched non-diabetic men. Plaque and gingival indices, bleeding scores, probing depth, loss of attachment, and number of missing teeth were measured in a blinded manner. Smoking status, glycemic control, socioeconomic status, and previous dental care were also assessed. These parameters were significantly higher in diabetic than non-diabetic men: plaque index, P < 0.0001; gingival index, P < 0.0002; bleeding score, P < 0.0001; probing depth, P = 0.0059; loss of attachment, P < 0.0001; and missing teeth, P < 0.005. These parameters were significantly higher in smokers than non-smokers: gingival index, probing depth, and loss of attachment. The duration of diabetes was not significantly related to the periodontal measures. Glycemic control as assessed by fasting plasma glucose and glycohemoglobin values was not significantly correlated to periodontal status. These studies indicate, for this study group, that diabetes significantly affects all measured parameters of periodontal status.

Periodontal diseases: epidemiology

1. The interpretation of epidemiological data of periodontal disease is difficult, due to inconsistencies in the methodology used. It is not possible, therefore, to accurately assess if the prevalence of the periodontal diseases shows a world-wide decline. As long as the disease is assessed through accumulated clinical attachment loss, retention of the natural dentition in older ages entails increased prevalence in these cohorts. Contemporary epidemiological studies should ideally employ full-mouth examination of the periodontal tissues. Partial recording estimates are generally biased, especially when the prevalence of the disease is low. 2. Early-onset periodontitis is infrequent in all populations. Adult periodontitis is rather prevalent; however, advanced disease affects limited subfractions of the population (probably less than 10 to 15%). Although prevalence figures vary with race and geographic region, in most cases, the progression pattern of the disease seems compatible with the retention of a functional dentition throughout life. 3. Of a plethora of behavioral and environmental risk markers identified by multi-variate analysis, smoking and presence of certain subgingival microorganisms have been proven to be true risk factors. The same holds true for diabetes mellitus, a systemic condition that confers a risk for periodontal disease which is independent of the effect of other significant factors. 4. In certain cases, periodontal infections appear to have a systemic impact on the host. Most recent data indicate that periodontal disease may confer risk for coronary heart disease and pre-term low birth weight.

Periodontal regeneration around natural teeth

1. Evidence is conclusive (Table 2) that periodontal regeneration in humans is possible following the use of bone grafts, guided tissue regeneration procedures, both without and in combination with bone grafts, and root demineralization procedures. 2. Clinically guided tissue regeneration procedures have demonstrated significant positive clinical change beyond that achieved with debridement alone in treating mandibular and maxillary (buccal only) Class II furcations. Similar data exist for intraosseous defects. Evidence suggests that the use of bone grafts or GTR procedures produce equal clinical benefit in treating intraosseous defects. Further research is necessary to evaluate GTR procedures compared to, or combined with, bone grafts in treating intraosseous defects. 3. Although there are some data suggesting hopeful results in Class II furcations, the clinical advantage of procedures combining present regenerative techniques remains to be demonstrated. Additional randomized controlled trials with sufficient power are needed to demonstrate the potential usefulness of these techniques. 4. Outcomes following regenerative attempts remain somewhat variable with differences in results between studies and individual subjects. Some of this variability is likely patient related in terms of compliance with plaque control and maintenance procedures, as well as personal habits; e.g., smoking. Variations in the defects selected for study may also affect predictability of outcomes along with other factors. 5. There is evidence to suggest that present regenerative techniques lead to significant amounts of regeneration at localized sites on specific teeth. However, if complete regeneration is to become a reality, additional stimuli to enhance the regenerative process are likely needed. Perhaps this will be accomplished in the future, with combined procedures that include appropriate polypeptide growth factors or tissue factors to provide additional stimulus.

Advanced glycation endproducts (AGEs) induce oxidant stress in the gingiva: a potential mechanism underlying accelerated periodontal disease associated with diabetes

We hypothesized that one mechanism underlying advanced periodontal disease in diabetes may involve oxidant stress in the gingiva, induced by the effects of Advanced Glycation Endproducts (AGEs), the irreversible products of non-enzymatic glycation and oxidation of proteins and lipids which accumulate in diabetic plasma and tissue. Infusion of AGE albumin, a prototypic ligand, into mice resulted in increased generation of thiobarbituric acid reactive substances (TBARS) compared with infusion of non-glycated albumin in the gingiva, as well as in the lung, kidney and brain. Pretreatment of the animals with the antioxidants probucol or N-acetylcysteine (NAC) prevented the generation of TBARS in the gingiva. Affinity-purified antibody to AGEs demonstrated increased immunoreactivity for AGEs in the vasculature and connective tissues of the gingiva in streptozotocin-induced diabetic mice compared to non-diabetic controls. Increased immunoreactivity for AGEs was also demonstrated in the gingiva of diabetic humans compared with non-diabetic individuals via immunohistochemistry and ELISA. Consistent with these data, immunohistochemistry for heme oxygenase-1, a marker of enhanced oxidant stress, was increased in the gingival vasculature of diabetic mice and humans compared with non-diabetic controls. These data suggest that AGEs present in diabetic gingiva may be associated with a state of enhanced oxidant stress, a potential mechanism for accelerated tissue injury.

The significance of bone in periodontal disease

Although the connective tissue attachment represents the key issue in periodontal health or disease and in periodontal therapy, the assessment of alveolar bone changes renders valuable indirect evidence for periodontal stability, progression of disease, or repair mechanisms. In periodontal disease bacterial products trigger host cells to release mediators, which may imbalance the steady state between resorption of bone and apposition of osteoid. Modulation of the hosts prostaglandin or interleukin-I synthesis by drug therapy could support the antimicrobial concept of periodontal therapy. Cross-sectional and long-term assessments of alveolar bone have been used to estimate the progression rate of periodontal disease. Inherent limitations of bone assessments in radiographs have to be considered when drawing conclusions from measurements that represent remodeling in periodontal lesions after therapy. Both bone quantity and quality seem to be of secondary importance with respect to the progression of disease, as well as response to therapy. Other risk factors that affect the microbial ecology and/or the hosts immune system seem to be the primary determinants for the periodontal health status.

Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics

The aim of this study was to define a population of diabetics exhibiting an increased risk of developing severe periodontitis by comparing the medical status of 2 groups of diabetics, 1 with no/minor periodontal disease and 1 with severe periodontal disease. The case-control study consisted of 2 parts, a baseline study and a follow-up study. 39 case-control pairs were selected. They were adult, long-duration, insulin-dependent diabetics matched according to sex, age and diabetes duration. One individual in each pair (the CASE) exhibited severe periodontal disease while the other (the CONTROL) exhibited gingivitis or only minor alveolar bone loss. The median age of the cases was 58 years (range 36 to 70 years) and of the controls 59 years (range 37 to 69 years). The median disease duration in cases and controls was 24 years and 25 years, respectively. The median follow-up time was 6 years. The medical variables analysed were weight, insulin dose, systolic and diastolic blood pressure, vibratory threshold, triglycerides, total-cholesterol, HDL-cholesterol, creatinine, HbA1, proteinuria, ECG, retinopathy, stroke, transient ischemic attacks (TIA), angina, myocardial infarct, heart failure, hypertension, intermittent claudication, foot ulcer, death, cause of death, and smoking habit. Biochemical analyses and clinical variables used as a routine in the monitoring of diabetics failed to differentiate between diabetics with severe and minor periodontal disease. In the follow-up study, significantly higher prevalences of proteinuria and cardiovascular complications such as stroke, TIA, angina, myocardial infarct and intermittent claudication were found in the case group. An association between renal disease, cardiovascular complications and severe periodontitis seems to exist. This indicates that a closer cooperation between the diabetologist and the dentist is necessary in monitoring the diabetic patient.

Risk assessment of recurrence of disease during supportive periodontal care. Epidemiological considerations

Although it is accepted that the primary cause of periodontitis is bacterial infection of long duration, there are a number of risk factors which may increase the probability of recurrence of periodontal disease during supportive periodontal care. The risk may in such cases be caused by other factors than poor oral hygiene measures per se. Cross-sectional and longitudinal studies show conflicting results concerning age as a risk factor for periodontal disease. The effect of smoking on the periodontal tissues has been discussed for decades and only lately has it been possible to demonstrate that smokers definitely have more periodontal problems than non-smokers. Another important risk factor for periodontitis relates to the insulin dependent and non-insulin dependent forms of diabetes mellitus. Poorly-controlled long-duration diabetics have more periodontitis and tooth loss than well-controlled or non-diabetics. Finally, the issue of compliance deserves attention. The medical literature has suggested that patients with chronic illnesses tend to comply poorly, especially if the disease is not perceived to be particularly threatening, if the therapy is time-consuming, or if the symptoms are non-disturbing. Suggestions for improved compliance are called for.

Dark field microscopy of the subgingival microflora in insulin-dependent diabetics

The subgingival microflora was assessed by means of dark field microscopy in 106 pockets of 47 subjects with long-term insulin-dependent diabetes mellitus (IDD). The microbiota of 55 healthy sulci (probing depth < 4 mm) and 51 periodontally diseased (probing depth > or = 4 and 6 mm) pockets were analyzed. The mean duration of the IDD of the diabetic subjects was 23.7 years (range from 10 to 41 years). The diabetic patients, aged 30-65 years, were under medical treatment at the III Department of Medicine, University of Helsinki Central Hospital, and at 2 clinics of the Helsinki Health Centre. Based upon their long-term medical records, 26 subjects were assessed to have poorly controlled insulin-dependent diabetes mellitus (PIDD) and 21 had controlled insulin-dependent diabetes (CIDD). The PIDD subjects exhibited higher mean blood glucose levels (12.9 +/- 4.6 mmol/l, mean +/- S.D.) than the CIDD subjects (7.9 +/- 3.6 mmol/l) (p < 0.001, t-test). The mean glycosylated hemoglobin HBA1 (HBA1c) levels were 11.2 +/- 4.6% (10.3 +/- 1.2%) and 8.8 +/- 1.8% (7.7 +/- 1.4%) for PIDD and CIDD subjects, respectively. These differences were statistically significant (p < 0.01 and p < 0.001, t-test). For each individual, site-specific recordings were made for plaque index and bleeding index scores, probing depth, loss of attachment and radiographic loss of alveolar bone. Dark field microscopy analysis of the presence of spirochetes, motile rods, cocci, non-motile rods, filaments and fusiforms was performed in the total of 106 pockets. According to the results of the dark field microscopy, the % of spirochetes and motile rods in the periodontally diseased pockets was significantly higher in the PIDD than in the CIDD subjects (9.2 +/- 13.4% and 10.8 +/- 14.3% versus 4.0 +/- 5.2% and 3.1 +/- 3.2%, p < 0.01 and p < 0.001, chi 2-test, respectively). Moreover, the PIDD subjects had lower mean %s of coccoid cells in periodontally diseased sites than the CIDD subjects (52.1 +/- 20.8% versus 60.7 +/- 9.0%, p < 0.001, chi 2-test).

Diabetic periodontitis: possible lipid-induced defect in tissue repair through alteration of macrophage phenotype and function

BACKGROUND

Diabetes mellitus is a major health problem in the United States affecting approximately 13 million people. The five 'classic' complications which have historically been associated with the condition are microangiopathy, neuropathy, nephropathy, microvascular disease, and delayed wound healing. Recently, periodontal disease (PD) has been declared the 'sixth' major complication of diabetes as diabetics demonstrate an increased incidence and severity of PD. The cellular and molecular basis for diabetic PD is unknown.

HYPOTHESIS

Recent evidence suggests that PD and delayed dermal wound healing may be manifestations of the same general systemic deficit in diabetes involving impairment of the cellular and molecular signal of wounding via alterations in macrophage phenotype. Diabetes-induced hyperlipidemia may interfere with the normal cellular and molecular signal of wounding by alteration of macrophage function and subsequent dysregulation of cytokines at the wound site.

RESULTS

Preliminary data in both animal models and humans suggests that hyperglycemia, in combination with elevations of serum low density lipoproteins and triglycerides, leads to formation of advanced glycation end products (AGEs) which may alter macrophage phenotype. This may be responsible for dysregulation of macrophage cytokine production and increased inflammatory tissue destruction and alveolar bone loss.

IMPLICATIONS

Future investigations will consider diabetic PD in the context of a generalized systemic wound healing deficit that manifests as PD in the face of constant pathologic wounding of the gingiva (bacterial plaque) or delayed dermal wound healing in instances of periodic traumatic wounding to other parts of the body. These types of studies will provide information concerning defective tissue repair in diabetics that will have clinical relevance for the understanding of PD and delayed dermal healing as well as applications of appropriate and specific therapies.

Association of the severity of periodontal disease with organ complications in type 1 diabetic patients

This study examined the relationship between the severity of periodontal disease and organ complications in long-term Type 1 or insulin-dependent diabetes mellitus patients, taking account of the severity and concomitant existence of these complications. The population studied consisted of 26 Type 1 diabetics 26 to 34 years old, who had had diabetes for at least 10 years. Severity of periodontal disease was shown to increase with severity of organ complications. Patients with advanced complications had significantly more bleeding on probing, pockets > or = 4 mm deep, and more attachment loss than patients with incipient complications or no complications. Stepwise multiple regression analysis showed that the existence of advanced complications was the only diabetes-related factor predicting pockets > or = 4 mm deep. Subgingival calculus, sex, and smoking were other significant variables. Retinopathy was the organ complication most suited to comparison, since it is usually the first to appear and can easily be classified from non-existent to severe. Differences in severity of periodontal disease were less obvious if metabolic balance alone was considered than between subgroups formed on the basis of the existence of advanced complications. Severity of periodontal disease and the existence of complications were more closely related to long-term glucose balance than single, most recent HbA1 values. Prevalence of pockets at sites with subgingival calculus increased with severity of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum fructosamine correlates with gingival index in children with insulin-dependent diabetes mellitus (IDDM)

Fructosamine assay, which is used in diagnosing and monitoring diabetic patients, is compared with the hemoglobin and plasma glucose assays in children and adolescent insulin-dependent diabetes mellitus patients. We demonstrated that the gingival index scores were correlated with fructosamine values in insulin-dependent diabetes mellitus patients but not in non-diabetic controls. We also found that there was no correlation between gingivitis scores and fasting plasma glucose and HbA1c values. Periodontitis was found to be rare in diabetic children and adolescents.

Prevalence of periodontal pathogens with varying metabolic control of diabetes mellitus

The purpose of this study was to determine the prevalence of 5 periodontal pathogens in individuals with diabetes mellitus. Subjects (n = 107) 20-70 years of age with type 1 (n = 60) or 2 (n = 47) diabetes mellitus were studied for the occurrence of the periodontal pathogens A. actinomycetemcomitans, F. nucleatum, E. corrodens, P. gingivalis and P. intermedia. Subgingival plaque was sampled in each subject from a single site exhibiting the greatest inflammation. The evaluation of selected periodontal bacterial pathogens was based on an immunoassay utilizing bacterial specific monoclonal antibodies. 35% of the sites harbored P. gingivalis, 28% F. nucleatum and 21% E. corrodens. A. actinomycetemcomitans and P. intermedia were found in less than 10% of the sites. Subjects for whom the probing depth at the sampled site was > or = 4 mm were more often found to have detectable pathogens than those with a probing depth < or = 3 mm. Diabetic factors such as duration, type and metabolic control of the disease had no statistically significant effect on the prevalence of these bacteria.

Preventive therapy for periodontal diseases

Rational approaches to the prevention of destructive periodontitis should be based on a clear understanding of etiology and pathogenesis. However, we are dealing with a heterogeneous family of diseases in which different factors operate. It is an oversimplification to regard poor oral hygiene, and hence an accumulation of non-specific dental bacterial plaque, as the major risk factor. Epidemiological evidence indicates that host factors are likely to be of overriding importance for the most severe forms. The limitations of nonspecific plaque control are therefore discussed. Specific inhibitors of virulence factors provide a logical approach, but their clinical application awaits improved knowledge. Improvement of general health and resistance to disease by proper nutrition, the avoidance of intercurrent disease, and elimination of smoking and stress-induced risk are encouraged. The genetic basis of susceptibility to periodontitis is increasingly understood, and, while gene therapy is not likely to be a practicable approach to prevention, genetic markers of risk are emerging.

Diabetes--a risk factor for periodontitis in adults?

With the increasing number of diabetics in an aging population and controversial research reports on the relationship of diabetes to periodontitis, clarification of diabetes as a risk factor for periodontitis would be helpful. This review notes variations in type, metabolic control, and duration of diabetes and highlights the results of studies that have considered these variations. Diabetics who maintained reasonably good metabolic control had not lost more teeth or experienced more periodontal attachment loss than non-diabetics, although they had more periodontal pockets. Poorly-controlled diabetics with extensive calculus on their teeth had more periodontitis and tooth loss than well-controlled diabetics or non-diabetics. Long-duration diabetics were also at greater risk for periodontitis. Mechanisms by which diabetes may contribute to periodontitis include vascular changes, neutrophil dysfunction, altered collagen synthesis, and genetic predisposition. Minimizing plaque and calculus in the oral cavity through careful self-care and regular professional care is important to reduce the risk of periodontitis in diabetics.

A site-by-site follow-up study on the effect of controlled versus poorly controlled insulin-dependent diabetes mellitus

In the present site-by-site follow-up study, the change in amount of approximal alveolar bone was assessed after 1 year from the baseline examination in 38 and after 2 years in 22 dentate subjects all with insulin-dependent diabetes mellitus. The diabetics, aged 35 to 56 years at baseline, had a history of a mean duration of 18 years of insulin-dependent diabetes mellitus and were under medical treatment at the outpatient clinic of the III Department of Medicine, University Central Hospital of Helsinki as well as at 2 diabetic clinics of the Helsinki Health Centre. Based upon their long-term medical records, 26 subjects were after 1 year, and 16 subjects after 2 years from the baseline, identified as having poorly controlled insulin-dependent diabetes (PIDD). At the 1-year examination, 12 subjects were classified as having controlled insulin-dependent diabetes (CIDD) as compared to 6 subjects at the 2-year examination. After 1 and 2 years, from baseline, site-by-site measurements were recorded for plaque index scores, bleeding after probing, loss of attachment, and radiographic loss of alveolar bone. After 1 and 2 years from baseline, the PIDD subjects exhibited higher mean %s of sites with improved bleeding scores (P < 0.01, chi 2-test) than the CIDD subjects. At the 2-year examination, the mean % of sites with loss of approximal alveolar bone was greater in the PIDD than in the CIDD group (P < 0.05, chi 2-test). The greatest differences between PIDD and CIDD subjects were found when recordings for only canines were analyzed at the 1- and 2-year examinations (P < 0.05, chi 2-test). The results of our current 2-year longitudinal site-by-site examinations confirm earlier results that poorly controlled insulin-dependent diabetes mellitus is strongly related to the amount of alveolar bone loss.

Periodontitis and tooth loss: comparing diabetics with the general population

People with diabetes may be at increased risk for periodontal disease. This study compared the periodontal health of diabetic and employed adults. While tooth loss and gingival attachment was similar for both groups, diabetics had a greater prevalence and extent of periodontal pockets. Diabetics with poor metabolic control and calculus also had more periodontitis.

Long-term control of diabetes mellitus and periodontitis

The purpose of this study was to evaluate the association between long-term control of diabetes mellitus (DM) and periodontitis. A total of 75 diabetics (Type I or II) aged 20-70 years with long-term records of their diabetic control were selected for the study. The following periodontal variables were recorded in a randomized half-mouth examination: plaque, calculus (+/-), probing depth (pd) and attachment loss (al). The mean of glycosylated hemoglobin measurements (HbAlc) over the past 2-5 years was used to indicate the long-term control of DM. The study participants were divided into well-, moderately- and poorly-controlled diabetics. An increase in the prevalence, severity and extent of periodontitis with poorer control of diabetes was observed. The extent of calculus also increased with poorer control. In a multiple regression analysis, calculus and long-term control of diabetes were significant variables when pd > or = 4 mm was used as the dependent variable. Age was a significant predictor for al > or = 3 mm but not for pd > or = 4 mm. Sex, duration and type of DM were not significant variables in the regression models. Less than 2% of sites with no calculus demonstrated pd > or = 4 mm. When calculus was present, the frequency of pd > or = 4 mm increased from 6% in the well-controlled diabetics to 16% in the poorly-controlled ones. We conclude that periodontitis in diabetics is associated with long-term metabolic control and presence of calculus.(ABSTRACT TRUNCATED AT 250 WORDS)

A longitudinal study on insulin-dependent diabetes mellitus and periodontal disease

In the present two-year longitudinal investigation, the progression of periodontal disease was assessed after 1 year from the baseline examination in 38 dentate subjects and after 2 years in 22 dentate subjects with a mean duration of 18 years of insulin-dependent diabetes mellitus. The diabetics, aged 35 to 56 years at baseline, were under medical treatment at the outpatient clinic of the III Department of Medicine, University Central Hospital of Helsinki and at 2 diabetic clinics of the Helsinki Health Centre. Based upon their long-term medical records, 26 subjects were at baseline identified as having poorly controlled insulin-dependent diabetes (PIDD) with a mean blood glucose level of 12.5 mmol/l and a mean glycosylated hemoglobin (HBA1) level of 10.1%. 12 subjects were classified as having controlled insulin-dependent diabetes (CIDD) with a mean blood glucose level of 6.7 mmol/l and a mean HBA1 level of 9.2% at baseline. For each individual, recordings were made at baseline and after 1 and 2 years from the baseline for the plaque index, gingival index, pocket depth, loss of attachment, bleeding after probing, gingival recession, and radiographic loss of alveolar bone. At baseline and 2 years after the baseline examination, the PIDD subjects had similar plaque conditions as the CIDD subjects. At baseline and after 1 and 2 years from baseline the PIDD subjects had more gingivitis and bleeding after probing (P < 0.05, chi 2-test) than the CIDD subjects.(ABSTRACT TRUNCATED AT 250 WORDS)