Influence of Diabetes Mellitus on the Severity of Periodontal Disease

Immediate response to nonsurgical periodontal treatment in subjects with diabetes mellitus

The short-term response (3-4 months) to non-surgical periodontal treatment, i.e., oral hygiene instruction, scaling and root planing, was determined in 34 diabetic and 45 control subjects. Measurements of probing pocket depth and gingival bleeding (%) were used for evaluation. No significant difference could be observed in the response to non-surgical periodontal treatment between the diabetics and controls.

Type 2 diabetes mellitus and periodontal disease

The relationship between type 2 diabetes mellitus and periodontal disease was evaluated in 2,878 Pima Indians of the southwestern United States. Two independent measures of periodontal disease, probing attachment loss and radiographic bone loss, were used to compare prevalence and severity of periodontal disease in diabetic and nondiabetic subjects. In all age groups studied, subjects with diabetes had a higher prevalence of periodontal disease, indicating that diabetes may be a risk factor for periodontal disease.

Tissue response to hydroxylapatite in induced diabetic and nondiabetic rats: histologic evaluation

This study evaluated the tissue response to the subcutaneous implantation of nonporous hydroxylapatite (HA) in 24 induced-diabetic (ID) and 24 nondiabetic (ND) rats. One cubic centimeter of HA was implanted subcutaneously in each rat's chest. Subgroups of 6 rats from the ID and ND groups were killed at 3, 6, 12, and 24 weeks postimplantation. The implants were removed with the surrounding soft tissues and processed for histologic evaluation. This revealed that soft tissue inflammation was mild at each time interval. There was a decreased response at 6 months in ND rats and a persistent inflammatory reaction in ID rats. Collagen maturity and fibroplasia increased within ND rats, whereas the ID rats showed a marked delay in collagen maturity and density. No osteogenesis was observed in any specimen. Dystrophic calcification was observed at the HA-tissue interface in 37% of ND and 59% of ID specimens. It was concluded that HA elicited a greater inflammatory response in ID than in ND rats when implated subcutaneously.

Relationship between bleeding/plaque ratio, family history of diabetes mellitus and impaired glucose tolerance

In the present study, the relationship between bleeding/plaque ratio, family history of diabetes mellitus and oral glucose tolerance pattern were investigated in 85 non-diabetic individuals without periodontal breakdown. In this group, no relationship between bleeding/plaque ratio, family history of diabetes mellitus and impaired glucose tolerance was found. The results of the present study suggest that the observed variation in bleeding/plaque ratio cannot be explained by impaired glucose tolerance or family history of diabetes mellitus. It is hypothesized that in subjects with impaired glucose tolerance, the periods of elevated blood glucose values may be too short to introduce tissue changes.

Rapid periodontal destruction in adult humans with poorly controlled diabetes. A report of 2 cases

Out of a pool of 12 middle-aged or elderly diabetic patients demonstrating rapid periodontal break-down, the 2 oldest cases with follow-up periods of 19 and 16 years are described. The common feature of all 12 patients was that they were either unaware of or unable to control their diabetic condition at the time of the active stage of their periodontal disease. The bone loss progressed in spite of specialist periodontal care and the patients again responded to treatment only after their elevated blood glucose levels had been brought back to normal. Thus, the rapid periodontal breakdown was not found to be associated with the diabetic condition per se, but rather with the hyperglycemia. This clinical follow-up study does not answer the question of whether rapid periodontal destruction occurs in all patients with poorly controlled diabetes. Neither do the observations imply that rapid bone loss would be pathognomic of high blood glucose levels. However, the observations seem to suggest that there may be an inter-relationship between rapid periodontal breakdown and elevated blood glucose levels. Therefore, any sudden change towards an increased progression rate of periodontal breakdown at adult age, as observed from periodic radiographs with intervals of only a few years, should be followed up with a medical examination in order to outrule or verify the possibility of a high blood glucose level.

Diabetes mellitus and periodontal disease in an Irish population

The prevalence of periodontitis was studied in a population of 157 insulin dependent diabetes mellitus patients aged 8-78 years attending the outpatients diabetic clinic of a large general hospital in Cork, Ireland. Every third diabetic patient attending the clinic was selected for examination. The dental parameters measured were plaque index (PI), gingivitis index (GI), periodontal pocket depth (PD) and periodontal attachment loss (PAL). Diabetic control was measured by estimating percentage haemoglobin glycolysation (% Hb Alc) known duration of diabetes (KDD) and insulin dependence. It was found that none of the diabetic measurements showed any consistent pattern in relation to any of the periodontal measurements. The findings are in agreement with other studies which suggest that no significant correlation between diabetic parameters and periodontal disease can be demonstrated. When the diabetic patient suffered periodontitis it was due to factors (such as genetic predisposition) other than impaired glucose metabolism.

Periodontal condition and microbiology of healthy and diseased periodontal pockets in type 1 diabetes mellitus patients

On the basis of glycosylated hemoglobin (HbA1c) values, 22 type 1 (insulin-dependent) diabetic adults were grouped into patients with near normal (HbA1c less than or equal to 7.7%) and poor (HbA1c greater than or equal to 9.9%) metabolic control. A total of 44 subgingival sites were examined for Actinobacillus actinomycetemcomitans, black-pigmented Bacteroides species and Capnocytophaga species. No significant difference could be demonstrated between patients in the 2 test groups with regard to periodontal condition. Neither age of diabetic patients nor duration of diabetes mellitus influenced the periodontal parameters. In both test groups, pocket depth of 4 mm or more (greater than or equal to 4 mm) was found to be significantly associated with increased swelling, bleeding after probing and amount of marginal plaque. Proportionally high %s of cultivable A. actinomycetemcomitans (mean 4.3%; range 2.8-5.8%), Bacteroides gingivalis (33.2% and 34.6%) and Bacteroides intermedius (mean 4.2%; range 0.001-13.5%) were isolated from diseased periodontal pockets. In diabetic patients with poor metabolic control, B. intermedius was isolated from diseased periodontal pockets with a mean % of 7.2%, range 0.3-12.5%. Independent of the degree of metabolic control, low %s of Capnocytophaga species were isolated from diseased and healthy periodontal pockets, mean 0.9% (range 0.003-3.9%) and mean 1.4% (range 0.04-4.9%), respectively. It was concluded from this study that metabolic control seems to have no direct effect on the periodontium. Furthermore, the rôle of Capnocytophaga species in the pathogenesis of infectious periodontal disease in type 1 diabetic patients seems to be overestimated.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal conditions in insulin-dependent diabetics

The aim of this study was to compare the prevalence and severity of periodontal disease in age- and sex-matched adult long- and short-duration insulin-dependent diabetics and non-diabetics. The study involved 82 subjects with long- and 72 with short-duration diabetes and 77 non-diabetics, all aged 20-70 years. The clinical and radiographic examination comprised recordings of the number of existing teeth, absence or presence of plaque and supra- and subgingival calculus, gingival conditions, probing pocket depth and alveolar bone level. There were no significant differences in the number of existing teeth or presence of plaque and supra- and subgingival calculus between long- and short-duration diabetics and non-diabetics. Diabetics, irrespective of the duration of the disease, had a higher prevalence of sites with gingivitis than non-diabetics. Overall, there were no significant differences between the groups regarding the prevalence of tooth surfaces with probing pocket depths of 4 and 5 mm. However, on comparison between age subgroups, long-duration diabetics younger than 45 years had significantly more 4 and 5 mm pockets than non-diabetics. Long-duration diabetics altogether had significantly more tooth surfaces with probing depth greater than or equal to 6 mm than non-diabetics. The radiographs of alveolar bone height exhibited significantly more extensive alveolar bone loss in long-duration diabetics aged 40-49 years than in short-duration diabetics and non-diabetics. This, together with the increased number of subjects belonging to classification groups with severe periodontal disease experience among long-duration diabetics, indicates more periodontal disease in these diabetics.

Dental and oral symptoms of diabetes mellitus

Dental and oral examinations of 1360 patients with diabetes mellitus showed higher DMFT mean values with fewer carious teeth and more filled and extracted teeth than the controls. PI mean values were higher in diabetics than in the controls, the difference being statistically significant, and showed a positive correlation with age, but no correlation with the length of time since the disease was established. No correlation was found between the severity of gingivitis and changes in blood glucose levels. The sucrose-free diet of diabetics does not seem to reduce caries prevalence. The increased DMFT index is explained by the fact that, due to periodontitis, diabetics lose more teeth sooner than do healthy people.

The relationship of inflammatory periodontal disease to diabetic status in insulin-dependent diabetes mellitus patients

This study was designed to evaluate the relationship of inflammatory periodontal disease to the diabetic status of the insulin-dependent diabetes mellitus (IDDM) patient. 52 IDDM patients, ages 11-22 years, were evaluated. These patients were closely monitored at regular intervals in the University of Kentucky pediatric diabetic clinic. A periodontal examination was carried out for each patient. The patients were then assigned to a periodontitis or non-periodontitis group. Moderate to advanced periodontitis was found in 5.8% of the subjects. The gingival index and sulcular bleeding index were significantly higher in the periodontitis group (P less than 0.05). There was no significant difference between groups for plaque index, age of diabetic onset, duration of diabetes, present age, insulin dosage/weight, or serum glucose (P greater than 0.05). There was a greater % of ketoacidosis, retinopathy and neuropathy in the periodontitis group. IDDM patients with neurological complications or a history of chronic infections had a significantly higher gingival index score than those without the complication (P less than 0.05).

Periodontal and caries experience in children with insulin-dependent diabetes mellitus

This study compared the periodontal and caries experience of young patients with insulin-dependent diabetes mellitus (IDDM) with a nondiabetic population of the same age. The plaque scores of children with IDDM were statistically higher. The caries experience of a child with closely monitored IDDM and a family history of diabetes was significantly lower than that of a child with IDDM and no such family history, even though the gingival and plaque indexes of both children were the same.

Oral health of patients with insulin-dependent diabetes mellitus

Oral health, the amount of salivary Streptococcus mutans and lactobacilli, and the flow rate, pH and buffer capacity of paraffin-stimulated whole saliva were analyzed in 35 adult diabetic patients and their age- and sex-matched non-diabetic, clinically healthy controls. All patients had insulin-dependent diabetes (IDDM) with a mean (+/- SD) duration of 14.0 +/- 9.1 yr. The prevalence of dental caries was as high in the diabetic group as in the controls but the past caries experience was remarkably lower in those individuals whose diabetes had started at a very early age (less than or equal to 7 yr). In agreement with the clinical data, the salivary levels of cariogenic microorganisms were of the same order of magnitude in both study groups. However, the relative proportion of S. mutans from the total cultivable aerobic microflora was significantly higher (P less than 0.01) in diabetics compared to the controls. The other studied salivary parameters did not differ between the groups. Remarkable individual differences were observed in the correlation between glucose levels of blood and whole saliva among diabetics. In spite of the noncariogenic dietary habits, the adult diabetic patients seem to be at least as susceptible to dental caries as non-diabetics, probably due to the leakage of glucose from blood into the oral cavity.

In vivo assay of crevicular leukocyte migration. Its development and potential applications

Defects in neutrophil or polymorphonuclear leukocyte (PMNL) chemotaxis have been observed in a number of clinical conditions, including Down's syndrome and insulin-dependent diabetes mellitus (IDDM), which tend to be associated with severe forms of periodontal disease. In addition, impaired PMNL chemotaxis is frequently detected in individuals with localized juvenile periodontitis (LJP). The ability to monitor PMNL function in vivo at the gingival sulcus should therefore be useful as a diagnostic test. In this regard, we developed a technique which measures the response of PMNLs to a chemotactic agent, e.g., casein and N-formylmethionylleucylphenylalanine (N-FMLP) placed directly into gingival crevices. The development of the technique and its relationship to in vitro assays of chemotaxis are discussed, and data obtained from tests of the assay on control and streptozotocin-induced diabetic rats and human subjects with various periodontal diseases and IDDM are presented. As compared with healthy subjects and control animals, atypical (double peak) and reduced crevicular PMNL response patterns were observed during oral and systemic diseases. This suggests that the in vivo assay with appropriate modifications can be used diagnostically to assess PMNL migratory dysfunction and to identify individuals who may be susceptible to severe forms of periodontal disease.

Diabetes mellitus and associated oral manifestations: a review

Oral research concerning diabetes mellitus has revealed a number of clinical implications. These include, among others, the need for more intense management of the diabetic patient with periodontal disease because tissue destruction may be accelerated, the need for rapid control of oral infection in these patients in order to prevent exacerbation of the existing metabolic imbalance, and the desirability of performing a screening for diabetes mellitus on all patients exhibiting asymptomatic parotid enlargement. Despite the explosion of knowledge concerning diabetes mellitus that has occurred since the discovery of insulin, its definitive etiology continues to elude the scientific community and its treatment remains in the realm of clinical management rather than in that of prevention and cure. In the past, research on diabetes has focused on the role of insulin in seeking the fundamental etiology of diabetes and its complications. With the progression of research, it has become apparent that the initiation and progression of the disease probably involve the interplay of a multiplicity of factors. Hereditary and immunologic factors, as suggested earlier, appear to be operated on by environmental factors, subsequently altering the body's metabolic milieu with widespread primary and secondary effects. Fertile areas for future oral research in diabetes mellitus will include, therefore, genetics, immunology, enzymology, and basement membrane pathology. On the cellular and molecular levels, particularly, the oral cavity and associated structures comprise a somewhat under-investigated area in diabetes mellitus research and, thus, hold great promise for increasing our knowledge of this complex disease.

Periodontal disease in juvenile and adult diabetic patients: a review of the literature

Epidemiologic studies have suggested that the severity of periodontitis is greater in juvenile and adult onset diabetes. In juvenile diabetic patients, the periodontal disease seems to be initiated around puberty and progresses by age. Reviewing the medical literature indicates a similar age of onset for known systemic complications resulting from diabetes. Angiopathy, abnormal collagen metabolism, abnormal PMN function, and altered sulcular microbial flora have been found to be closely associated with the severity of periodontitis in diabetic patients. The association between abnormal neutrophil function and severity of periodontal disease in diabetic patients provides an opportunity for examining the role of neutrophil in periodontal disease. Future investigation in the function of sulcular PMN may shed light on the complex mechanism of periodontal disease.

The effect of streptozotocin-induced diabetes on prolyl hydroxylase activity in rat gingiva

The diabetes resulted in marked decrease in prolyl hydroxylase (EC 1.14.11.2) activity in rat gingiva. Insulin treatment of diabetic rats returned the decreased enzyme activity to the level of normal controls. The results suggest that diabetes decreases the rate of collagen biosynthesis in gingival tissue by inhibiting the hydroxylation of peptidyl proline in collagen precursors.

The development of an altered gingival crevicular microflora in the alloxan-diabetic rat

The microflora of the rat gingival crevice were examined at various time intervals after inducing experimental diabetes. A variety of Gram-positive and Gram-negative cocci and short rods were isolated from the normal rat crevice. Within a week after alloxan administration, Leptotrichia buccalis was detected for the first time. Other features in the diabetic animals included an increased frequency of isolation of Proteus spp., Lactobacillus spp. and decrease of Escherichia coli. Occasionally, a decrease was also observed in Bacteroides spp. and Streptococcus spp. No difference was observed between diabetic and non-diabetic animals in the isolation of Selonomonas, Campylobacter, Bifidobacterium and Actinomyces. Plaque accumulation was markedly increased in the diabetic rats. It was concluded that the change in gingival microflora resulted from diabetes-induced alterations in the sulcular environment (such as increased substrate levels, e.g. glucose and urea, and decreased oxygen) and that the microbiological changes preceded the depending of the periodontal pocket.

Diabetes and periodontal diseases. Possible role of vitamin c deficiency: an hypothesis

An hypothesis is proposed relating the possible role of vitamin deficiency as an etiologic factor contributing to periodontal disease in diabetes. The hypothesis is based upon the following: (1) transport of ascorbate across cell membranes may be impaired by glucose, but facilitated by insulin; (2) glucose utilization is significantly accelerated by sublethal concentrations of endotoxin; (3) endotoxin-induced histamine sensitivity of tissue is enhanced by ascorbic deficiency; and (4) ascorbic acid deficiency alters mucosal barrier function. The interrelationship of these factors is discussed.

A bitewing radiographic study of a population of diabetic and nondiabetic rhesus monkeys

A population of 7 diabetic and 13 nondiabetic rhesus monkeys (Macacca mulatta) were examined radiographically using bitewing imaging techniques. Each subject was scored radiographically for bone levels, periodontal ligament (PDL) widening, radiographic calculus, and carious lesions. Prior to examinations blood samples were obtained for fasting blood glucose levels. Results indicated that all clinical variables were generally greater for the diabetic group, with bone loss being the only statistically significant parameter. Calculus levels, however, were found to be greater radiographically in the nondiabetic group. In viewing the study population as a single group of 20 monkeys, decreased bone levels were found to be positively correlated with PDL widening and blood glucose levels suggesting an association of hyperglycemic states with possible decreased resistance to infection. It was concluded that carbohydrate intolerance with hyperglycemia in diabetes mellitus may be associated with the radiographic variable of increased bone resorption using an objective system of measurement for evaluation and scoring. Without a quantitative system of measurement such as devised in this study, other radiographic variables such as PDL widening, calculus deposits, and carious lesions may not be accurately tested against one another or correlated with other experimental clinical parameters.

Gingival inflammation in diabetic children related to degree of metabolic control

Earlier studies indicate that diabetic children are less resistant to periodontal disease than healthy children. As the degree of metabolic control of the diabetes ranges widely in a juvenile population, the susceptibility to gingival inflammation may vary. The aim of the present study was to compare the gingival status in diabetic children, subgrouped for control of the disease, with that in non-diabetic children. All comparisons were performed under controlled plaque conditions. 43 diabetic children took part in the study. The controls consisted of age- and sex-matched healthy children. The degree of gingival inflammation and the amount of bacterial plaque were assessed in terms of the Gingival Index and the Plaque Index, respectively. The Plaque Index scores constituted the basis for all comparisons of gingival status. The metabolic control of the diabetics was assessed from the amount of glycosylated hemoglobin fraction HbA1c. For children with the highest Plaque Index scores, diabetics showed statistically significantly higher Gingival Index scores. Only minor differences were seen in the other Plaque Index classes. The diabetic children with poor metabolic control showed a clear tendency towards higher Gingival Index scores than the non-diabetics, while no such tendency was seen between the diabetics with good metabolic control and the non-diabetics.

Enhanced collagenase activity in diabetic rat gingiva: in vitro and in vivo evidence

Gingiva from alloxan and streptozotocin-diabetic rats exhibited markedly enhanced collagenolytic activity in tissue culture. This effect was eliminated by puromycin or by repeated freeze-thawing of the tissue prior to incubation. Soluble extracts of the diabetic gingiva in situ were found to contain breakdown products of collagen similar in size to the reaction products generated by tissue collagenase. These fragments were not detected in the control tissue. This study indicates that experimental diabetes stimulates the synthesis of gingival collagenase in culture and that a similar effect occurs in vivo.

Diabetes mellitus and periodontal disease

A sample of 54 patients with diabetes mellitus were subjects to detailed assessment of periodontal disease levels using standard indices. In order to determine whether the severity of periodontal disease was related to the severity of diabets mellitus, a series of parameters of the diabetes mellitus population was simultaneously studied. There were no significant relationships between the levels of periodontal disease and the duration of diabetes, the type of treatment and the frequency of systemic complications. Periodontal disease in the diabetic appeared to the affected by the same etiologic factors [plaque, calculus, neglect] as would be expected in nondiabetic patients. Further studies with larger population samples would be appropriate.

Influence of obesity and hypertension on the severity of periodontitis in rats

The purpose of this investigation was to evaluate the extent to which obesity and/or hypertension may modify the response of rats' periodontium to chronic gingival irritation. Forty-four normal, spontaneously hypertensive, obese, and obese-hypertensive rats were used. Histopathologic evaluation of the periodontal structure showed both hyperplasia and hypertrophy of the walls of blood vessels supplying the periodontium in the hypertensive and obese-hypertensive animals. The results also indicated that obesity significantly contributed to e severity of periodontal disease. Hypertension alone was not a significant factor. The obese-hypertensive rats showed the most severe periodontal response to local irritation.