Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

Diabetes and oral health: an overview

BACKGROUND

Diabetes is a common disease with concomitant oral manifestations that impact dental care. The purpose of this review is to summarize the prevalence, signs, symptoms, diagnosis and treatment of diabetes, as well as dental treatment considerations for the patient with diabetes.

CONCLUSIONS

Safely managing the patient with diabetes requires effective communication among multiple health care providers. Dentists must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patients with diabetes.

PRACTICE IMPLICATIONS

Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment.

Diabetes in the dental office: using NHANES III to estimate the probability of undiagnosed disease

BACKGROUND AND OBJECTIVE

Recent data have suggested that in the past 15 years there has been a dramatic increase in the incidence of diabetes mellitus in the USA. However, evidence suggests that approximately one-third of diabetes cases remain undiagnosed. Because 60% of Americans see a dentist at least once per year for routine, nonemergent, care, it is reasonable to propose that the dental office can be a healthcare location actively involved in screening for unidentified diabetes.

MATERIAL AND METHODS

This study used NHANES III to develop a predictive equation that can form the basis of a tool to help dentists determine the probability of undiagnosed diabetes by using self-reported data and periodontal clinical parameters routinely assessed in the dental office.

RESULTS

Our analyses reveal that individuals with a self-reported family history of diabetes, hypertension, high cholesterol levels and clinical evidence of periodontal disease bear a probability of 27-53% of having undiagnosed diabetes, with Mexican-American men exhibiting the highest probability and white women the lowest.

CONCLUSION

These findings suggest that the dental office could provide an important opportunity to identify individuals unaware of their diabetic status.

Effect of non-surgical periodontal therapy on clinical and immunological response and glycaemic control in type 2 diabetic patients with moderate periodontitis

OBJECTIVES

The purpose of this study was to compare the local efficacy of nonsurgical periodontal therapy between type 2 diabetic and non-diabetic patients and the effect of periodontal therapy on glycaemic control.

BACKGROUND

A complex two-way relationship exists between diabetes mellitus and periodontitis.

MATERIALS AND METHODS

After selection, 20 subjects (10 diabetic and 10 non-diabetic) underwent baseline examination, periodontal clinical study and biochemical analysis of gingival crevicular fluid (GCF). After the pre-treatment phase, subgingival scaling and root planing were performed. Subsequently, all subjects continued the maintenance programme and were re-examined at 3 and 6 months.

RESULTS

Diabetic and non-diabetic subjects responded well after therapy, showing a very similar progression during the follow-up period. Both groups showed clinically and immunologically significant improvements. Significant reductions were also found in the total volume of GCF and levels of interleukin-1beta and tumour necrosis factor-alpha. Diabetic subjects showed an improvement in their metabolic control. The change in glycosylated haemoglobin (HbA(1C)) was statistically significant at 3 and 6 months.

CONCLUSIONS

The clinical and immunological improvements obtained were accompanied by a significant reduction in HbA(1C) values in type 2 diabetic subjects. Larger studies are needed to confirm this finding and establish whether periodontal therapy has a significant effect on glycaemic control.

Associations between periodontal diseases and systemic diseases: a review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular diseases and osteoporosis

The aim of this review article is to examine the associations between periodontal diseases and common systemic diseases, namely diabetes, respiratory diseases, cardiovascular diseases and osteoporosis. A substantial number of review articles have been published to elucidate the relationships between these diseases; however, none provide a complete overview on this topic from the aspects of definition, classification, clinical characteristics and manifestations, inter-relationships and interactions, proposed schematic mechanisms, clinical implications and management of periodontal patients with these systemic diseases. The aim of this article is to provide an overall understanding and general concepts of these issues in a concise and inter-related manner.

The oral cavity of elderly patients in diabetes

Diabetes mellitus is a common and growing global health problem leading to several complications. Among these periodontal diseases are considered as the sixth complication of diabetes mellitus. This article reviews the relationship between diabetes and oral health, particularly focusing on periodontal diseases, dental caries and xerostomia. There is a bidirectional interrelationship between diabetes and periodontal diseases. Periodontitis is more prevalent and severe in patients with diabetes than in normal population. Therapy of periodontal infection contributes to a positive glycaemic control management and enables reduction of the burden of complications of diabetes mellitus. Diabetics have an increased predisposition to the manifestation of oral diseases like candidiasis which is associated with poor glycaemic control and therapeutic dentures. This predisposition also contributes to xerostomia, which may be due to increased glucose levels in oral fluids or immune dysregulation.

Diabetes-related parameters and periodontal conditions in children

BACKGROUND AND OBJECTIVE

The relationship between diabetes and periodontal diseases is well established. Our aim in this study was to explore the diabetes-related parameters that are associated with accelerated periodontal destruction in diabetic youth.

MATERIAL AND METHODS

Three-hundred and fifty 6-18-year-old children with diabetes received a periodontal examination. Data on important diabetes-related variables were collected. Analyses were performed using logistic regression, with gingival/periodontal disease as the dependent variable, for the whole cohort and separately for two subgroups (6-11 and 12-18 years of age).

RESULTS

Regression analyses, adjusting for age, gender, ethnicity, frequency of prior dental visits, dental plaque, and dental examiner, revealed a strong positive association between mean hemoglobin A1c over the 2 years prior to inclusion in the study and periodontitis (odds ratio = 1.31, p = 0.030). This association approached significance in the younger subgroup (odds ratio = 1.56, p = 0.052, n = 183). There was no significant relationship between diabetes duration or body mass index-for-age and measures of gingival/periodontal disease in this cohort.

CONCLUSION

These findings suggest that accelerated periodontal destruction in young people with diabetes is related to the level of metabolic control. Good metabolic control may be important in addressing periodontal complications in young patients with diabetes, similarly to what is well established for other systemic complications of this disease.

Periodontitis is associated with aggravation of prediabetes in Zucker fatty rats

BACKGROUND

Prediabetes is part of the natural history of type 2 diabetes. Few human studies have addressed the relationship between periodontitis and prediabetes. The Zucker fatty rat (ZFR) is a known model of prediabetes, characterized by hyperinsulinemia, dyslipidemia, and moderate hypertension. The aim of the present study was to investigate whether periodontitis affects the prediabetic state of ZFRs.

METHODS

Male adult ZFRs (fa/fa; N = 24) and their lean littermates (+/fa; N = 24) were studied. Periodontitis was induced with ligatures in half of the ZFRs and lean rats, whereas the other half served as controls. After 4 weeks, body weight, food intake, glucose tolerance, insulin resistance, free fatty acids, cytokines, and alveolar bone loss were recorded.

RESULTS

ZFRs with periodontitis presented increased glucose intolerance (P = 0.03) and a slight increase in fasting glucose from initial to final evaluation, as detected through paired analysis (P = 0.03). Among lean rats, those with periodontitis presented higher final glucose intolerance than those without periodontitis (P = 0.01). Furthermore, periodontitis in lean rats was associated with increased fasting glucose, insulin, and insulin resistance, as evaluated through paired analysis (P = 0.003, P = 0.008, and P = 0.001, respectively). Regarding alveolar bone analysis, ZFRs with periodontitis demonstrated significantly more bone loss compared to lean rats with periodontitis (P <0.001).

CONCLUSIONS

Prediabetes worsened periodontitis, and periodontitis, in turn, was associated with deterioration of glucose metabolism in ZFRs, suggesting a progress toward diabetes. Furthermore, periodontitis also affected glucose regulation in lean rats.

Diabetes mellitus promotes periodontal destruction in children

AIM

The association between diabetes mellitus and periodontal attachment and bone loss is well established. Most of the prior literature has focused on adults, and studies in children have mostly reported gingival changes. Our aim was to assess the periodontal status of a large cohort of children and adolescents with diabetes.

MATERIAL AND METHODS

We examined 350 children with diabetes (cases) and 350 non-diabetic controls (6-18 years of age). Using three different case definitions for periodontal disease, which incorporated gingival bleeding and/or attachment loss findings, multiple logistic regression analyses adjusting for age, gender, ethnicity, frequency of prior dental visits, dental plaque, and examiner were performed.

RESULTS

Subjects with diabetes had increased gingival inflammation and attachment loss compared with controls. Regression analyses revealed statistically significant differences in periodontal destruction between cases and controls across all disease definitions tested (odds ratios ranging from 1.84 to 3.72). The effect of diabetes on periodontal destruction remained significant when we separately analysed 6-11 and 12-18 year old subgroups.

CONCLUSIONS

These findings demonstrate an association between diabetes and an increased risk for periodontal destruction even very early in life, and suggest that programmes to address periodontal needs should be the standard of care for diabetic youth.

The prevalence of inflammatory periodontitis is negatively associated with serum antioxidant concentrations

Chronic periodontitis is an inflammatory disease that affects the supporting tissues of the teeth. It is initiated by specific bacteria within the plaque biofilm and progresses due to an abnormal inflammatory-immune response to those bacteria. Periodontitis is the major cause of tooth loss and is also significantly associated with an increased risk of stroke, type-2 diabetes and atheromatous heart disease. Oxidative stress is reported in periodontitis both locally and peripherally (serum), providing potential mechanistic links between periodontitis and systemic inflammatory diseases. It is therefore important to examine serum antioxidant concentrations in periodontal health/disease, both at an individual species and total antioxidant (TAOC) level. To determine whether serum antioxidant concentrations were associated with altered relative risk for periodontitis, we used multiple logistic regression for dual case definitions (both mild and severe disease) of periodontitis in an analysis of 11,480 NHANES III adult participants (>20 y of age). Serum concentrations of vitamin C, bilirubin, and TAOC were inversely associated with periodontitis, the association being stronger in severe disease. Vitamin C and TAOC remained protective in never-smokers. Higher serum antioxidant concentrations were associated with lower odds ratios for severe periodontitis of 0.53 (CI, 0.42,0.68) for vitamin C, 0.65 (0.49,0.93) for bilirubin, and 0.63 (0.47,0.85) for TAOC. In the subpopulation of never-smokers, the protective effect was more pronounced: 0.38 (0.26,0.63, vitamin C) and 0.55 (0.33,0.93, TAOC). Increased serum antioxidant concentrations are associated with a reduced relative risk of periodontitis even in never-smokers.

Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes

OBJECTIVE

The purpose of this study was to investigate the effect of periodontitis on development of overt nephropathy, defined as macroalbuminuria, and end-stage renal disease (ESRD) in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Individuals residing in the Gila River Indian Community aged > or =25 years with type 2 diabetes, one or more periodontal examination, estimated glomerular filtration rate > or =60 ml/min per 1.73 m(2), and no macroalbuminuria (urinary albumin-to-creatinine ratio > or =300 mg/g) were identified. Periodontitis was classified as none/mild, moderate, severe, or edentulous using number of teeth and alveolar bone score. Subjects were followed to development of macroalbuminuria or ESRD, defined as onset of renal replacement therapy or death attributed to diabetic nephropathy.

RESULTS

Of the 529 individuals, 107 (20%) had none/mild periodontitis, 200 (38%) had moderate periodontitis, 117 (22%) had severe periodontitis, and 105 (20%) were edentulous at baseline. During follow-up of up to 22 years, 193 individuals developed macroalbuminuria and 68 developed ESRD. Age- and sex-adjusted incidence of macroalbuminuria and ESRD increased with severity of periodontitis. After adjustment for age, sex, diabetes duration, BMI, and smoking in a proportional hazards model, the incidences of macroalbuminuria were 2.0, 2.1, and 2.6 times as high in individuals with moderate or severe periodontitis or those who were edentulous, respectively, compared with those with none/mild periodontitis (P = 0.01). Incidences of ESRD in individuals with moderate or severe periodontitis or in those who were edentulous were 2.3, 3.5, and 4.9 times as high, respectively, compared with those with none/mild periodontitis (P = 0.02).

CONCLUSIONS

Periodontitis predicts development of overt nephropathy and ESRD in individuals with type 2 diabetes. Whether treatment of periodontitis will reduce the risk of diabetic kidney disease remains to be determined.

Study design, recruitment, and baseline characteristics: the Department of Veterans Affairs Dental Diabetes Study

OBJECTIVES

We are conducting a clinical trial of the efficacy of periodontal therapy in the improvement of glycaemic control in veterans with poorly controlled diabetes. This report describes study design, recruitment and randomization and compares baseline characteristics of the sample frame with those randomized into study groups.

METHODS

Veterans with poorly controlled diabetes were randomized in two groups: immediate periodontal therapy ("early treatment") or usual care followed by periodontal therapy ("deferred treatment"). Half of each group continued care for 12 months; the other half returned to their usual care. We studied baseline patient characteristics, self-reported health measures, and clinical examination data. We examined means for continuous variables, frequencies for categorical variables and compared groups using t-tests and chi(2) tests (alpha=0.05 for both).

RESULTS

The 193 randomized participants were younger (58 years) and had slightly higher HbA1c (10.2%) than the 2534 non-randomized participants (64 years, HbA1c =9.8%). The deferred treatment group was more likely than the early treatment group to have a history of stroke, transient ischaemic attacks, and less likely to be current or former smokers.

CONCLUSIONS

The mechanism for randomization was largely successful in this study.

An elderly case of type 2 diabetes which developed in association with oral and esophageal candidiasis

A 75-year-old woman who had been healthy except for mild glycemia and lipidemia discovered three and a half months before admission experienced severe dysphagia secondary to oral and esophageal candidiasis. She eventually developed diabetic hyperosmolar syndrome and ketoacidosis. Since anti-GAD antibody was negative and her diabetes was controlled with a moderate dose of insulin, we made a diagnosis of type 2 diabetes. Her only risk factors for candidiasis were hyperglycemia, age, and continuous denture use. The fact that her diabetes developed in association with oral candidiasis supports the hypothesis that there is a bidirectional interrelationship between diabetes and oral infection.

Does periodontal care improve glycemic control? The Department of Veterans Affairs Dental Diabetes Study

OBJECTIVES

Report results of a randomized-clinical trial of the efficacy of periodontal care in the improvement of glycemic control in 165 veterans with poorly controlled diabetes over 4 months.

METHODS

Outcomes were change in Haemoglobin A1c (HbA1c) in the Early Treatment versus untreated (Usual Care) groups and percent of participants with decreases in HbA1c. Analyses included simple/multiple variable linear/logistic regressions, adjusted for baseline HbA1c, age, and duration of diabetes.

RESULTS

Unadjusted analyses showed no differences between groups. After adjustment for baseline HbA1c, age, and diabetes duration, the mean absolute HbA1c change in the Early Treatment group was -0.65% versus -0.51% in the Usual Care group (p=0.47). Adjusted odds for improvement by 0.5% in the Early Treatment group was 1.67 (95% confidence interval: 0.84, 3.34, p=0.14). Usual Care subjects were twice as likely to increase insulin from baseline to 4 months (20% versus 11%, p=0.12) and less likely to decrease insulin (1% versus 6%, p=0.21) than Early Treatment subjects. Among insulin users at baseline, more increased insulin in the Usual Care group (40% versus 21%, p=0.06).

CONCLUSIONS

No significant benefit was found for periodontal therapy after 4 months in this study; trends in some results were in favour of periodontal treatment.

Distribution of Genotypes of Porphyromonas gingivalis in Type 2 Diabetic Patients with Periodontitis in Mexico

OBJECTIVE

To determine and compare the distribution of Porphyromonas gingivalis fimA genotypes in type 2 diabetes mellitus (T2DM) patients affected by periodontitis, using non-diabetic subjects with and without periodontitis as control groups.

MATERIAL AND METHODS

This study involved 75 subjects divided into three groups of 25 subjects each: Group 1 (non-T2DM without periodontitis), Group 2 (non-T2DM with periodontitis) and Group 3 (T2DM with periodontitis). The outcome variable was periodontitis, and explanatory variables were age, sex, T2DM and specific P. gingivalis fimA genotypes.

RESULTS

In non-T2DM subjects with healthy periodontal tissues, type I fimA was the most frequently detected individually (40%) or in combinations (40%). In non-T2DM subjects with periodontitis, the most frequently detected type was Ib individually (20%) or in combinations (36%). In T2DM patients with periodontitis, the most frequently detected types were types I (20%) and III (20%), but there was no statistical difference (p>0.05) with non-T2DM periodontitis subjects.

CONCLUSIONS

Type I genotype was more frequently detected in periodontally healthy sites from non-T2DM subjects than in periodontitis sites from either subjects with or without T2DM. However, in sites affected by periodontitis from T2DM subjects the predominating types were I and III, which are less virulent strains of P. gingivalis.

Periodontal treatment associated with improved glycaemic control in type 2 diabetic patients

DESIGN

This was a randomised controlled trial (RCT).

INTERVENTION

Patients randomised to the treatment group received oral hygiene instruction, full-mouth scaling and root planing performed under local anaesthesia. The control group received no periodontal treatment during the study period, but after completion of the study these patients were given full nonsurgical and supportive periodontal treatment if needed.

OUTCOME MEASURE

Plaque index (PI), gingival index (GI), probing pocket depth (PPD), gingival recession (GR), and bleeding on probing (BOP) were recorded . Venous blood samples were taken from each patient baseline and at the third month following the periodontal treatment; these were analysed for fasting plasma glucose (FPG), 2-h post-prandial glucose (PPG), glycated haemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), high-density and low-density lipoprotein cholesterol and microalbuminurea.

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 not statistically significant increase for this parameter.

CONCLUSIONS

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

Addressing health care disparities and increasing workforce diversity: the next step for the dental, medical, and public health professions

The racial/ethnic composition of our nation is projected to change drastically in the coming decades. It is therefore important that the health professions improve their efforts to provide culturally competent care to all patients. We reviewed literature concerning health care disparities and workforce diversity issues--particularly within the oral health field--and provide a synthesis of recommendations to address these issues. This review is highly relevant to both the medical and public health professions, because they are facing similar disparity and workforce issues. In addition, the recent establishment of relationships between oral health and certain systemic health conditions will elevate oral health promotion and disease prevention as important points of intervention in the quest to improve our nation's public health.

Relationship between smoking status and periodontal conditions: findings from national databases in Japan

BACKGROUND AND OBJECTIVE

The association between cigarette smoking and periodontitis was examined employing two nationally representative samples of adults in Japan.

MATERIAL AND METHODS

Data were derived from the Survey of Dental Diseases (SDD) and the National Nutrition Survey (NNS) in 1999. In the SDD, periodontal conditions were evaluated by calibrated dentists utilizing the Community Periodontal Index (CPI), whereas in the NNS, participants were interviewed on the basis of smoking status by enumerators. Among 6805 records electronically linked via a household identification code, 4828 records of individuals aged 20 yr or older were analyzed.

RESULTS

The prevalence of periodontal disease varied significantly by smoking status (p < 0.0001): 39.3%, 49.5% and 47.3% (CPI > or = 3), and 7.9%, 11.7% and 12.4% (a more severe form of periodontitis, CPI = 4), for nonsmokers, former smokers and current smokers, respectively. In adults aged > or = 40 yr (n = 3493), logistic regression models revealed greater probabilities (approximately 1.4 times higher) of periodontitis [CPI > or = 3, odds ratio = 1.38 (1.12-1.71), p = 0.0024] and a more severe form of periodontitis [odds ratio = 1.40 (1.04-1.89), p = 0.0288] in current smokers compared with nonsmokers, following adjustment for possible confounding factors.

CONCLUSION

Based on the findings of this study and other numerous reports, cigarette smoking leads to deterioration of periodontal conditions in Japanese adults.

Plasma levels of tumour necrosis factor-alpha in patients with chronic periodontitis and type 2 diabetes

OBJECTIVES

Studies suggest that elevated circulating tumour necrosis factor-alpha (TNF-alpha) may contribute to insulin resistance in patients with type 2 diabetes. The source of plasma TNF has been thought to be adipocytes associated with obesity, but inflammation and infection result in TNF-alpha production as well.

METHODS

We studied 46 patients with type 2 diabetes and chronic periodontitis to determine the relationship between plasma TNF-alpha levels and clinical measures of periodontitis, gingival crevicular fluid (GCF) interleukin-1beta (IL-1beta), plasma endotoxin, serum glucose, and glycated haemoglobin (HbA1c). TNF-alpha levels were measured using a high sensitivity enzyme-linked immunosorbent assay.

RESULTS

TNF-alpha showed a significant positive correlation with attachment loss (r=0.40, p=0.009), plasma endotoxin (r=0.33, p=0.03), and GCF IL-1beta (r=0.33, p=0.035), but not probing depth (r=0.28, p=0.07), bleeding on probing (r=0.30, p=0.053), plaque index (r=0.22, p=0.17), serum glucose, HbA1c (r=0.10, p=0.50), or body mass index (r=0.077, p=0.62). A dose-response relationship was observed between periodontitis severity and TNF-alpha (p=0.012).

CONCLUSION

The finding that chronic periodontitis is associated with plasma TNF-alpha levels in subjects with type 2 diabetes supports the hypothesis that periodontal infection and inflammation may contribute to insulin resistance.

The views of dentists, nurses and nutritionists on the association between diabetes and periodontal disease: a qualitative study in a Latino community

OBJECTIVE

To interview health professionals in a Latino community about the association between diabetes and periodontitis, and provide a basis to develop interventions for them to promote oral health and good glycemic control among patients with diabetes.

METHODS

Five dentists, seven nurses and two nutritionists were interviewed about their practices relevant to oral health and diabetes, knowledge about the association, beliefs about Latinos, recommendations on reaching others in their fields, and barriers. The interviews were audiotaped, transcribed, and analyzed qualitatively.

RESULTS

Professionals identified policy, community and practice barriers for promoting diabetic control and oral health.

CONCLUSIONS

Producing a resource list, cross-educating professionals about diabetes and oral health, training professionals to better serve Latino patients, developing appropriate protocols for each profession regarding the association between diabetes and periodontitis, and educating the community about diabetic control, oral health and disease prevention were identified as potential strategies to improve oral health among Latino persons with diabetes.

Periodontitis and Gestational Diabetes Mellitus: Exploring the Link in NHANES III

OBJECTIVES

The authors hypothesized that women with a history of gestational diabetes mellitus (GDM) during pregnancy would exhibit more severe periodontal disease than controls without a history of diabetes during pregnancy.

METHODS

Data from NHANES Ill provided information for 4,244 women ages 20-59. One hundred and thirteen had a history of GDM (GDM+), while 4,131 had no history of diabetes before or during their pregnancies (GDM-). Women were further classified by the presence or absence of diabetes mellitus (DM+ or DM-) at the time of their NHANES Ill examination. Periodontal disease (PD) was defined as one or more teeth with one or more sites with probing depth > or = 4mm, loss of attachment > or = 2mm, and bleeding on probing.

RESULTS

The PD prevalence among women who were GDM+DM- was 9.0% and 4.8% for those who were GDM-DM-. PD prevalence for women who were GDM+DM+ was 30.5% and 11.6% for GDM-DM+ subjects, respectively. A logistic regression model, controlling for age, calculus, smoking, and income estimated women who were GDM+DM+ were more likely to have periodontal disease than women who were GDM-DM- and women who were GDM-DM+. The GDM+DM- group also tended to be more likely to have PD than the GDM-DM- and GDM-DM+ groups. However, the odds ratios were not statistically significant.

CONCLUSIONS

These results support the hypothesis that women with gestational diabetes mellitus (GDM) during pregnancy may be at greater risk for developing more severe periodontal disease than pregnant women without GDM.

Levels of immunoglobulin A1 and messenger RNA for interferon gamma and tumor necrosis factor alpha in total saliva from patients with diabetes mellitus type 2 with chronic periodontal disease

BACKGROUND

Diabetes mellitus and periodontal disease have high incidence in the general population and are associated with various degrees of dysfunction in the immune system. It has been shown that diabetic patients with severe periodontal disease have more complications of diabetes and less effective metabolic control compared with diabetic patients with healthy gingiva. Patients with diabetes and severe periodontal disease present higher levels of serous immunoglobulin A (IgA). Elevation of the IgA1 isotype is thought to contribute to this phenomenon. Another important event in the diabetes-periodontitis association is the disturbance in local and systemic production of inflammatory cytokines.

OBJECTIVE

In this study we tested the hypothesis that type 2 diabetic patients with chronic moderate periodontal disease have differences in salivary IgA1 titers and cytokine expression when compared with the chronic severe periodontal disease cases.

METHODS

We utilized a jacalin-IgA capture assay to determine the IgA1 titers in total saliva and reverse transcriptase-polymerase chain reaction to detect mRNA for interferon gamma (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha) in total saliva samples of 13 patients with chronic moderate periodontal disease and 10 with chronic severe periodontal disease.

RESULTS AND CONCLUSIONS

We observed a predominance of IgA1 titers of 64 (45.5%) in saliva samples from chronic severe periodontal disease patients and titers averaging 512 (30.8%) in chronic moderate periodontal disease patients. We detected mRNA for IFN-gamma in six out of 10 chronic severe periodontal disease subjects and in two out of 13 chronic moderate periodontal disease patients. TNF-alpha expression was similar in both groups. Our data suggest that higher levels of IgA1 may exert partial protection of the periodontal tissue in chronic moderate periodontal disease diabetic patients when compared to severe periodontal disease. Despite the small number of patients, IFN-gamma expression had a trend association with severity of periodontitis and TNF-alpha gene expression did not correlate with severity of periodontal disease.

Association between serum albumin and periodontal disease in community-dwelling elderly

AIM

The purpose of this study was to evaluate the relationship between periodontal disease and general health status in community-dwelling elderly using serum albumin concentration as a criterion index of the severity of an underlying disease and nutrition status.

METHODS

Serum albumin level was detected by the bromcresol green albumin (BCG) method and the data for serum albumin were available in 368 subjects aged 75 years. Pressure-sensitive probes were used to measure loss of attachment (LA) on six sites of all teeth present. Information relevant to gender and smoking habit was obtained by means of a personal interview, while body mass index (BMI) and biochemical serum markers were investigated.

RESULTS

Serum albumin concentration ranged from 3.2 to 4.8 g/dl with a mean of 4.1+/-0.2. More than 70% of subjects had at least one site with LA 6+ mm, while 91 exhibited 10% or more sites with LA 6+ mm. Using a multiple regression analysis, we found that sites of LA 6+ mm had a significant effect on serum albumin level (correlation coefficient=-0.14; p<0.05), which was independent of the other covariates.

CONCLUSIONS

The findings of the present study indicated that there might be an inverse relationship between periodontal disease and serum albumin concentration in these elderly subjects.

Diabetes-enhanced inflammation and apoptosis--impact on periodontal pathology

Diabetes, particularly type 2 diabetes, is a looming health issue with many ramifications. Because diabetes alters the cellular microenvironment in many different types of tissues, it causes myriad untoward effects, collectively referred to as 'diabetic complications'. Two cellular processes affected by diabetes are inflammation and apoptosis. This review discusses how diabetes-enhanced inflammation and apoptosis may affect the oral environment. In particular, dysregulation of tumor necrosis factor and the formation of advanced glycation products, both of which occur at higher levels in diabetic humans and animal models, potentiate inflammatory responses and induce apoptosis of matrix-producing cells. The enhanced loss of fibroblasts and osteoblasts through apoptosis in diabetics could contribute to limited repair of injured tissue, particularly when combined with other known deficits in diabetic wound-healing. These findings may shed light on diabetes-enhanced risk of periodontal diseases.

Periodontal changes in children and adolescents with diabetes: a case-control study

OBJECTIVE

To evaluate the level of oral disease in children and adolescents with diabetes.

RESEARCH DESIGN AND METHODS

Dental caries and periodontal disease were clinically assessed in 182 children and adolescents (6-18 years of age) with diabetes and 160 nondiabetic control subjects.

RESULTS

There were no differences between case and control subjects with respect to dental caries. Children with diabetes had significantly higher plaque and gingival inflammation levels compared with control subjects. The number of teeth with evidence of attachment loss (the hallmark of periodontal disease) was significantly greater in children with diabetes (5.79 +/- 5.34 vs. 1.53 +/- 3.05 in control subjects, unadjusted P < 0.001). When controlling for age, sex, ethnicity, gingival bleeding, and frequency of dental visits, diabetes remained a highly significant correlate of periodontitis, especially in the 12- to 18-year-old subgroup. In the case group, BMI was significantly correlated with destruction of connective tissue attachment and bone, but duration of diabetes and mean HbA(1c) were not.

CONCLUSIONS

Our findings suggest that periodontal destruction can start very early in life in diabetes and becomes more prominent as children become adolescents. Programs designed to promote periodontal disease prevention and treatment should be provided to young patients with diabetes.

Does periodontal treatment improve glycemic control in diabetic patients? A meta-analysis of intervention studies

Previous analyses regarding effects of periodontal treatment on glycemic control included studies where causal association might not be assumed, or the results were reported non-quantitatively. We initiated this meta-analysis of 10 intervention studies to quantify the effects of periodontal treatment on HbA1c level among diabetic patients, to explore possible causes for the discrepant reports, and to make recommendations for future studies. Data sources were MEDLINE (January, 1980, to January, 2005), the EBMR, Cochrane Register, and bibliographies of the published articles. Three investigators extracted data regarding intervention, outcomes, and effect size. A total of 456 patients was included in this analysis, with periodontal treatment as predictor and the actual change in hemoglobin A1c level as the outcome. The weighted average decrease in actual HbA1c level was 0.38% for all studies, 0.66% when restricted to type 2 diabetic patients, and 0.71% if antibiotics were given to them. However, none was statistically significant.

Characterization of the ultrastructure of gingival mast cells in alloxan-induced diabetic rats

The morphological changes of gingival mast cells of alloxan-induced diabetic rats were studied by electron microscopy. The following observations were made. The cell nucleus and cytoplasm degenerated. The electron density of the granules in the cell cytoplasm clearly decreased. Some granules had dense irregular threads and the granules were surrounded by a thin vacuole. A ghost vacuole formed in some mast cells and disorganized materials accumulated in the cytoplasm. The mast cell nuclei were generally irregular and degenerating mast cells had pyknotic nuclei. General destruction of the cell membrane and granule shedding in some samples was noted and mitochondria with atypical cristae in the cytoplasm of the mast cells were seen. We conclude that the characteristics of the ultrastructure of gingival mast cells in diabetics are distinctive and should be used as criteria for pathogenesis of gingival inflammation.

Strengthening the Prevention of Periodontal Disease: The WHO Approach

BACKGROUND

The aim of this paper is to provide an overview of the burden of periodontal disease in adult populations worldwide, to emphasize the essential risk factors common to periodontal disease and chronic diseases, to outline important new strategies for effective prevention of periodontal disease, and to inform about the role of the World Health Organization (WHO) in developing a national capacity for the prevention of disease.

METHODS

Information about periodontal health status as measured by the Community Periodontal Index system is stored in the WHO Global Oral Health Data Bank. Updated information concerning WHO standard age groups was used to describe the prevalence rates of signs of periodontal disease, i.e., gingival bleeding, periodontal pocketing, and loss of attachment.

RESULTS

Gingival bleeding is highly prevalent among adult populations in all regions of the world; advanced disease with deep periodontal pockets (> or =6 mm) affects approximately 10% to 15% of adults worldwide. The available evidence shows that important risk factors for periodontal disease relate to poor oral hygiene, tobacco use, excessive alcohol consumption, stress, and diabetes mellitus. Integrated preventive strategies based on the common risk factors approach are recommended for public health practice.

CONCLUSIONS

The vast majority of countries need to establish a surveillance system for measuring progress in the control of periodontal disease and promotion of oral health. WHO has designed approaches for the integration of oral disease prevention within the prevention of non-communicable chronic diseases, and global strategies are currently being implemented in all regions of the world.

Periodontal diseases

The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.

Disease progression: identification of high-risk groups and individuals for periodontitis

AIMS

While the role of bacteria in the initiation of periodontitis is primary, a range of host-related factors influence the onset, clinical presentation and rate of progression of disease. The objectives of this review are (1) to present evidence for individual predictive factors associated with a patient's susceptibility to progression of periodontitis and (2) to describe the use of prognostic models aimed at identifying high-risk groups and individuals in a clinical setting.

METHODS

Relevant publications in the English language were identified after Medline and PubMed database searches. Because of a paucity of longitudinal studies investigating factors including clinical, demographic, environmental, behavioural, psychosocial, genetic, systemic and microbiologic parameters to identify individuals at risk for disease progression, some association studies were also included in this review.

FINDINGS AND CONCLUSIONS

Cigarette smoking is a strong predictor of progressive periodontitis, the effect of which is dose related. High levels of specific bacteria have been predictive of progressive periodontitis in some studies but not all. Diabetics with poor glycaemic control have an increased risk for progression of periodontitis. The evidence for the effect of a number of putative factors including interleukin-1 genotype, osteoporosis and psychosocial factors is inconclusive and requires further investigation in prospective longitudinal studies. Specific and sensitive diagnostic tests for the identification of individuals susceptible to disease progression are not yet a reality. While factors assessed independently may not be valuable in predicting risk of future attachment loss, the combination of factors in a multifactorial model may be useful in identifying individuals at risk for disease progression. A number of multifactorial models for risk assessment, at a subject level have been developed but require validation in prospective longitudinal studies.

Analytical epidemiology of periodontitis

AIMS

To review the literature related to the analytical epidemiology of periodontitis generated over the past decade. This review does not deal with descriptive epidemiologic studies of the prevalence, extent and severity of periodontitis with respect to global geography, but focuses exclusively on analytical epidemiology issues, including the challenges posed by the use of different case definitions across studies, current theories and models of disease progression, and risk factors associated with the onset and progression of periodontitis.

METHODS

Relevant publications in the English language were identified after Medline and PubMed database searches.

FINDINGS AND CONCLUSIONS

There is a conspicuous lack of uniformity in the definition of periodontitis used in epidemiologic studies, and findings from different research groups are not readily interpretable. There is a lack of studies that specifically address the distinction between factors responsible for the onset of periodontitis versus those affecting its progression. Colonization by specific bacteria at high levels, smoking, and poorly controlled diabetes have been established as risk factors for periodontitis, while a number of putative factors, including specific gene polymorphisms, have been identified in association studies. There is a clear need for longitudinal prospective studies that address hypotheses emerging from the cross-sectional data and include established risk factors as covariates along with new exposures of interest. Intervention studies, fulfilling the "targeting" step of the risk assessment process, are particularly warranted. Obvious candidates in this context are studies of the efficacy of elimination of specific bacterial species and of smoking cessation interventions as an alternative to the traditional broad anti-plaque approach in the prevention and control of periodontitis. Ideally, such studies should have a randomized-controlled trial design.

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.

Geriatric oral health and pneumonia risk

The oral cavity is a complex microenvironment consisting of multiple bacterial and fungal species, their associated biofilms, and a cytokine milieu influenced by constant inflammatory stimulation. Multiple infectious consequences of poor oral health have been extensively described and primarily affect older adults. Probably the most common sequelae of poor oral health in aged persons is a risk of aspiration pneumonia. The risk of aspiration pneumonia is greatest when periodontal disease, dental caries, and poor oral hygiene are compounded by swallowing disease, feeding problems, and poor functional status. The effectiveness of oral hygiene interventions for preventing aspiration pneumonia and barriers to oral care of nursing home patients require additional study, but the current state of research in these areas is reviewed in this manuscript. The expense of aspiration pneumonia as a nursing home complication makes dental hygiene a potentially cost-saving intervention.

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 attachment loss in an urban population of Brazilian adults: effect of demographic, behavioral, and environmental risk indicators

BACKGROUND

There is little information about the occurrence and risk factors of periodontal diseases in developing countries. This study describes the clinical attachment loss (CAL) in an adult Brazilian population and performs a risk assessment of demographic, behavioral, and environmental exposures.

METHODS

A representative sample of 853 dentate individuals (age: 30 to 103 years) was selected by a multistage probability sampling method. The subjects had a full-mouth clinical examination of six sites per tooth and were interviewed using a structured written questionnaire.

RESULTS

Seventy-nine percent (79%) and 52% of the subjects and 36% and 16% of the teeth per subject had CAL > or = 5 and > or = 7 mm, respectively. A multivariable model showed that 40 to 49 and > or = 50 years olds had 3.0 and 5.9 times higher risk for moderate CAL and 7.4 and 25.4 times higher risk for severe CAL, compared to the 30 to 39 years olds. Moderate cigarette smokers had a significantly higher risk for moderate (relative risk ratio [RRR] = 2.1) and severe CAL (RRR = 3.4), and heavy smokers had a higher risk for moderate (RRR = 3.0) and severe CAL (RRR = 8.2) compared to non-smokers. A significantly higher risk for severe CAL was also present in males (RRR = 1.6), subjects with low (RRR = 1.8) or medium socioeconomic status (RRR = 1.6), and those with a history of irregular dental visits (RRR = 2.1). Diabetic status and race did not show significant associations with CAL after adjusting for other effects.

CONCLUSIONS

This Brazilian population had a high occurrence of attachment loss. A population-based strategy that includes the establishment of prevention and health promotion programs targeting high-risk groups is highly desirable for controlling the high occurrence of attachment loss in this population.

Therapy with adjunctive doxycycline local delivery in patients with type 1 diabetes mellitus and periodontitis

OBJECTIVES

The purpose of this study was to evaluate the effect of subgingival administration of doxycycline as an adjunct to periodontal therapy in type 1 diabetes mellitus (DM) patients.

MATERIAL AND METHODS

Twenty-two paired periodontal defects > or =5.0 mm were treated in 11 patients (35-55 years old). After initial therapy the sites were randomly assigned into test (scaling and root planing+subgingival administration of 10% doxycycline hyclate gel) or control (scaling and root planing+subgingival placebo gel) groups. The clinical parameters of clinical attachment level (CAL), probing depth (PD) and gingival margin level (GML) for recession determination were assessed at baseline, after 6 weeks, and 6, 9 and 12 months, using a computerized probe. Data were statistically evaluated using Duncan and F tests.

RESULTS

Between study group comparisons indicated PD reduction and CAL gain were greater in the test group than in the control group at 6 weeks and 6, 9 and 12 months but only statistically significant at 12 months (p<0.05). Within study group comparisons indicated statistically significant differences were found for CAL and PD values favouring the adjunctive doxycycline group from baseline to 6 weeks and 6, 9 and 12 months (p<0.05).

CONCLUSIONS

These findings suggest that subgingivally delivered doxycycline hyclate produces additional favorable clinical results to periodontal therapy in type 1 DM patients.

The relationship between tomato intake and congestive heart failure risk in periodontitis subjects

BACKGROUND

The objective of this study was to investigate the relationship between monthly tomato consumption (MTC) and serum lycopene (sLyco) levels, and a self-reported history of congestive heart failure (CHF) in individuals with periodontitis using data available in the Third National Health and Nutrition Examination Survey (NHANES III).

METHODS

Adult participants in NHANES III were used in this study. Zero to thirty three percent of sites with a periodontal attachment loss (PAL) of >3 mm was considered a healthy periodontium, while greater than >33% of sites with PAL of >3 mm as periodontitis. The outcome variable was the self-reported history of CHF. MTC and sLyco levels were categorized into quartiles. Data was analyzed by Kruskal-Wallis, anova and multivariate analyses using SPSS(R). p<0.05 was used to reject the null hypothesis.

RESULTS

Individuals with periodontitis showed a dose-response relationship between dietary MTC and self-reported CHF risk; moderate MTC (risk ratio (RR), 3.15; 95% confidence interval (CI), 1.03-9.67), low MTC (RR, 3.31; 95% CI, 1.33-8.24) (p<0.05) and very low MTC (RR, 5.10; 95% CI, 1.67-15.57) (p<0.01), adjusting for confounders of both diseases (periodontitis and CHF). The moderate sLyco level-healthy periodontium group showed a significant decrease in CHF risk (RR, 0.25; 95% CI, 0.07-0.84) (p<0.05), adjusting for confounders. Significant inverse dose-response relationships were seen between sLyco and C-reactive protein, and MTC and white blood cell count in periodontitis subjects, respectively (p<0.05). MTC was correlated with sLyco concentration (r=-0.018, p<0.05), adjusting for confounders abolished that significance.

CONCLUSIONS

A relationship exists between periodontitis and CHF risk, and high MTC appears to affect this relationship in a positive direction in periodontitis subjects.

Oral disease burden in Northern Manhattan patients with diabetes mellitus

OBJECTIVES

We explored the association between diabetes mellitus and oral disease in a low-socioeconomic-status urban population.

METHODS

Dental records of 150 adults with diabetes and 150 nondiabetic controls from the dental clinic at Columbia University in Northern Manhattan matched by age and gender were studied.

RESULTS

There was a 50% increase in alveolar bone loss in diabetic patients compared with nondiabetic controls. Diabetes, increasing age, male gender, and use of tobacco products had a statistically significant effect on bone loss.

CONCLUSIONS

Our findings provide evidence that diabetes is an added risk for oral disease in this low-income, underserved population of Northern Manhattan. Oral disease prevention and treatment programs may need to be part of the standards of continuing care for patients with diabetes