Non-insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years

The effect of periodontal therapy on uncontrolled type 2 diabetes mellitus in older subjects

OBJECTIVE

The purpose of this study was to examine the effect of periodontal therapy on glycemic control in older type 2 diabetic patients.

METHODS

Fifty-two diabetic patients, age 55-80 years (mean age = 61 years), with glycated hemoglobin (HbA1c) 7.5-11.0% (mean +/- s.d. = 8.98 +/- 0.88) and severe periodontitis were included in the present study. The treatment group received mechanical periodontal treatment combined with systemic doxycycline, 100 mg day(-1) for 14 days. The control group received neither periodontal treatment nor systemic doxycycline. Clinical periodontal parameters, fasting plasma glucose (FPG), and HbA1c levels were measures at baseline and 3 months.

RESULTS

Periodontal treatment significantly improved periodontal status of the treatment group (P < 0.05), however the reduction in the level of FPG and HbA1c did not reach significance. In the control group, no significant changes in clinical periodontal parameters, FPG and HbA1c levels were observed, except for significant increase in attachment loss (P < 0.05). Comparing the two groups, although the 3-month level of HbA1c of the treatment group was lower than that of the control group, the difference did not reach significance.

CONCLUSIONS

The results of the present study indicate that the periodontal condition of older Thais with uncontrolled diabetes is: (a) significantly improved 3 months after mechanical periodontal therapy with adjunctive systemic antimicrobial treatment, and (b) rapidly deteriorating without periodontal treatment. The effect of periodontal therapy on the glycemic control of older uncontrolled diabetics will require further studies that will have to include much larger sample sizes.

Effect of non-surgical periodontal treatment with or without doxycycline on the periodontium of type 1 diabetic patients

AIM

The present investigation was performed to study how type 1 diabetics responded to non-surgical periodontal treatment with and without adjunctive doxycycline.

METHOD

Sixty diabetic type 1 patients (mean age 35.3+/-9 years) with moderate-to-severe periodontal disease were selected and divided into two groups of 30 patients each. Both groups were sex and age matched and had similar amounts of periodontal destruction. Plaque index (PI), bleeding on probing (BOP), probing depth (PD) and clinical attachment levels (CAL) were recorded. Group 1 (30 patients) was treated with oral hygiene instruction, scaling and root planing, chlorhexidine rinses twice a day and doxycycline (100 mg/day for 15 days). Group 2 (30 patients) had the same treatment but without doxycycline. After 12 weeks their periodontal condition was reevaluated.

RESULTS

After treatment, both groups had a significant improvement in all periodontal parameters, since PI, BOP, probing pocket depth (PPD) and CAL were significantly reduced. However, the reduction in PD in pockets > or =6 mm and in BOP were more evident when doxycycline was used (group 1). Differences between groups for these parameters were statistically significant (p=0.03).

CONCLUSION

Although both periodontal treatment regimens are effective in type 1 diabetics, the use of doxycycline as an adjunct, provided more significant results when good plaque control was achieved.

The National Institute of Dental and Craniofacial Research: research for the practicing dentist

BACKGROUND AND OVERVIEW

Established in 1948, the National Institute of Dental and Craniofacial Research (NIDCR) has helped transform dentistry into a profession that is based firmly in prevention and technological innovation. This article introduces the new NIDCR initiative in general dentistry practice-based research. It also highlights research supported by the NIDCR and its implications for dental practice in restorative dentistry, oral and systemic disease, stem cell research, salivary diagnostics, gene transfer therapy and pain.

CLINICAL IMPLICATIONS

The NIDCR supports research that will help guide the practitioner in the delivery of patient care and have a direct impact on the practice of dentistry.

The effect of improved periodontal health on metabolic control in type 2 diabetes mellitus

OBJECTIVES

The aim of the present study was to investigate the effect of improved periodontal health on metabolic control in type 2 diabetes mellitus (DM) patients.

MATERIAL AND METHODS

Fourty-four patients with type 2 DM were selected. Subjects were randomly assigned into two groups.

DATA COLLECTION

Plaque index (PI), gingival index (GI), probing pocket depth (PPD), clinical attachment levels (CALs), gingival recession (GR) and bleeding on probing (BOP) were recorded at baseline at 1st and 3rd months. Fasting plasma glucose (FPG), 2-h post-prandial glucose (PPG), glycated haemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), HDL-cholesterol, LDL-cholesterol and microalbuminure were analysed at baseline, 3 months following the periodontal therapy. The treatment group received full-mouth scaling and root planing whereas the control group received no periodontal treatment.

RESULTS

A statistically significant effect could be demonstrated for PI, GI, PPD, CAL and BOP for the treatment group. HbA1c levels in the treatment group decreased significantly whereas the control group showed a slight but insignificant increase for this parameter.

CONCLUSIONS

The results of our study showed that non-surgical periodontal treatment is associated with improved glycaemic control in type 2 patients and could be undertaken along with the standard measures for the diabetic patient care.

Periodontal disease and mortality in type 2 diabetes

OBJECTIVE

Periodontal disease may contribute to the increased mortality associated with diabetes.

RESEARCH DESIGN AND METHODS

In a prospective longitudinal study of 628 subjects aged > or =35 years, we examined the effect of periodontal disease on overall and cardiovascular disease mortality in Pima Indians with type 2 diabetes. Periodontal abnormality was classified as no or mild, moderate, and severe, based on panoramic radiographs and clinical dental examinations.

RESULTS

During a median follow-up of 11 years (range 0.3-16), 204 subjects died. The age- and sex-adjusted death rates for all natural causes expressed as the number of deaths per 1,000 person-years of follow-up were 3.7 (95% CI 0.7-6.6) for no or mild periodontal disease, 19.6 (10.7-28.5) for moderate periodontal disease, and 28.4 (22.3-34.6) for severe periodontal disease. Periodontal disease predicted deaths from ischemic heart disease (IHD) (P trend = 0.04) and diabetic nephropathy (P trend < 0.01). Death rates from other causes were not associated with periodontal disease. After adjustment for age, sex, duration of diabetes, HbA1c, macroalbuminuria, BMI, serum cholesterol concentration, hypertension, electrocardiographic abnormalities, and current smoking in a proportional hazards model, subjects with severe periodontal disease had 3.2 times the risk (95% CI 1.1-9.3) of cardiorenal mortality (IHD and diabetic nephropathy combined) compared with the reference group (no or mild periodontal disease and moderate periodontal disease combined).

CONCLUSIONS

Periodontal disease is a strong predictor of mortality from IHD and diabetic nephropathy in Pima Indians with type 2 diabetes. The effect of periodontal disease is in addition to the effects of traditional risk factors for these diseases.

Periodontal disease and diabetes mellitus

Infections of the tissue surrounding the teeth (periodontitis) are usually caused by anaerobic gram-negative microorganisms. This infection causes destruction of the supporting alveolar bone and can lead to tooth loss. Removal of these microorganisms can slow or arrest the progression of periodontitis. Diabetes patients are at greater risk of developing periodontitis, may not respond as well to periodontal therapy as nondiabetic patients, and may require more aggressive treatment to manage periodontitis. Microorganisms that cause periodontitis and the host response to these may increase insulin resistance in diabetic patients. Treatment of periodontitis could improve glycemic control. A model is presented in which periodontal pathogens may cause increases in proinflammatory cytokines that mediate increases in insulin resistance, resulting in an increase in blood glucose. Following periodontal therapy, this process may be reversed.

Alveolar bone loss associated with glucose tolerance in Japanese men

AIMS

Type 2 diabetes is known to affect alveolar bone loss (ABL). The purpose of this study was to examine whether impaired glucose tolerance (IGT) is associated with ABL, as is diabetes.

METHODS

A case-control study was performed with 664 Japanese men aged 46-57 years. Panoramic radiographs revealed 513 severe ABL cases, 22 moderate ABL cases, and 129 controls with good alveolar bone. Diabetes status was classified into normal glucose tolerance (NGT), impaired fasting glucose (IFG), IGT, and newly diagnosed diabetes according to the fasting plasma glucose and 75-g oral glucose tolerance test (OGTT). Diabetes under treatment was excluded. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from ordinal logistic regression analysis. Statistical adjustment was made for total cholesterol, HDL-cholesterol, triglyceride, rank in the Self Defence Forces (SDF), cigarette-years, alcohol use, body mass index, previous 10 years' brushing habits and instrument use other than toothbrush, and history of periodontal treatment.

RESULTS

A significant, approximately three-fold increase in the crude OR (crude OR=3.28; 95% CI=1.16-9.27) and non-significant 2.6-fold increase in the adjusted OR (adjusted OR=2.55; 95% CI=0.86, 7.54) of ABL was observed among men with newly diagnosed Type 2 diabetes compared with the reference group (NGT combined with IFG). However, there was no association between IGT and ABL (adjusted OR=0.99; 95% CI=0.59,1.64).

CONCLUSIONS

Type 2 diabetes, but not IGT, was positively associated with ABL. Preventive maintenance against periodontitis is important in middle-aged men with diabetes.

Infectious complications of dental and periodontal diseases in the elderly population

Retention of teeth into advanced age makes caries and periodontitis lifelong concerns. Dental caries occurs when acidic metabolites of oral streptococci dissolve enamel and dentin. Dissolution progresses to cavitation and, if untreated, to bacterial invasion of dental pulp, whereby oral bacteria access the bloodstream. Oral organisms have been linked to infections of the endocardium, meninges, mediastinum, vertebrae, hepatobiliary system, and prosthetic joints. Periodontitis is a pathogen-specific, lytic inflammatory reaction to dental plaque that degrades the tooth attachment. Periodontal disease is more severe and less readily controlled in people with diabetes; impaired glycemic control may exacerbate host response. Aspiration of oropharyngeal (including periodontal) pathogens is the dominant cause of nursing home-acquired pneumonia; factors reflecting poor oral health strongly correlate with increased risk of developing aspiration pneumonia. Bloodborne periodontopathic organisms may play a role in atherosclerosis. Daily oral hygiene practice and receipt of regular dental care are cost-effective means for minimizing morbidity of oral infections and their nonoral sequelae.

Periodontal risk assessment, diagnosis and treatment planning

The prevention and treatment of the periodontal diseases is based on accurate diagnosis, reduction or elimination of causative agents, risk management and correction of the harmful effects of disease. Prominent and confirmed risk factors or risk predictors for periodontitis in adults include smoking, diabetes, race, P. gingivalis, P. intermedia, low education, infrequent dental attendance and genetic influences. Several other specific periodontal bacteria, herpesviruses, increased age, male, sex, depression, race, traumatic occlusion and female osteoporosis in the presence of heavy dental calculus have been shown to be associated with loss of periodontal support and can be considered to be risk indicators of periodontitis. The presence of furcation involvement, tooth mobility, and a parafunctional habit without the use of a biteguard are associated with a poorer periodontal prognosis following periodontal therapy. An accurate diagnosis can only be made by a thorough evaluation of data that have been systematically collected by: 1) patient interview, 2) medical consultation as indicated, 3) clinical periodontal examination, 4) radiographic examination, and 5) laboratory tests as needed. Clinical signs of periodontal disease such as pocket depth, loss of clinical attachment and bone loss are cumulative measures of past disease. They do not provide the dentist with a current assessment of disease activity. In an attempt to improve the ability to predict future disease progression, several types of diagnostic tests have been studied, including host inflammatory products and mediators, enzymes, tissue breakdown products and subgingival temperature. In general, the usefulness of these tests for predicting future disease activity remains to be established in terms of sensitivity, specificity and predictive value. Although microbiological analysis of subgingival plaque is not necessary to diagnose and treat most patients with periodontitis, it is helpful when treating patients with unusual forms of periodontal disease such as early-onset, refractory and rapidly progressive disease. There appears to be a strong genetic component in some types of periodontal disease and genetic testing for disease susceptibility has potential for future use, but more research is needed to determine its utility for use in clinical practice. Treatment of the periodontal diseases may be divided into four phases: systemic, hygienic, corrective and maintenance or supportive periodontal therapy. Regardless of the type of treatment provided, periodontal therapy will fail or will be less effective in the absence of adequate supportive periodontal therapy.

Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

This review evaluates evidence for a bidirectional relationship between diabetes and periodontal diseases. A comprehensive Medline search of the post-1960 English language literature was employed to identify primary research reports of relationships between diabetes and periodontal diseases. Reports included in the review on the adverse effects of diabetes on periodontal health (DM-->PD) were restricted to those comparing periodontal health in subjects with and without diabetes. Review of adverse affects of periodontal infection on glycemic control included reports of periodontal treatment studies and follow-up observational studies in which changes in glycemic control could be assessed. Observational studies reporting DM-->PD provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal diseases in the large majority of reports (supportive evidence in 44/48 total reviewed; 37/41 cross-sectional and 7/7 cohort). Additionally, there were no studies reviewed with superior design features to refute this association. Treatment studies provided direct evidence to support periodontal infection having an adverse, yet modifiable, effect on glycemic control. However, not all investigations reported an improvement in glycemic control after periodontal treatment. Additional evidence to support the effect of severe periodontitis on increased risk for poorer glycemic control comes from 2 follow-up observational studies. The evidence reviewed supports viewing the relationship between diabetes and periodontal diseases as bidirectional. Further rigorous, systematic study is warranted to establish that treating periodontal infections can be influential in contributing to glycemic control management and possibly to the reduction of the burden of complications of diabetes mellitus.

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.

Recent advances in diabetes mellitus of interest to dentistry

Significant changes were made in 1997 by The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus of the American Association of Diabetes regarding the diagnosis and classification of diabetes mellitus. The terms "insulin-dependent diabetes mellitus" (IDDM) and "non-insulin-dependent diabetes mellitus" (NIDDM) were dropped. The new classification is, in general, based on etiology rather than on treatment and includes four groups: Type I (autoimmune), Type 2 (non-autoimmune), Other specific types, and Gestational diabetes. The fasting blood glucose level for diagnosis was lowered from 140 mg/dL to 126 mg/dL. A random blood glucose of 200 mg/dL or greater in a patient with symptoms of diabetes is diagnostic. Each of these diagnostic tests needs to be repeated on a separate day. The glucose tolerance test is no longer recommended for routine diagnostic use. Recommendations for the screening of diabetes mellitus in presumably healthy individuals are presented. New advances in insulin and its delivery to the diabetic patient are discussed. The impact of diabetes mellitus on the oral cavity is updated.

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.