Comparative evaluation of adjunctive oral irrigation in diabetics

Oral Irrigation Devices: A Scoping Review

OBJECTIVES

Self-performed oral hygiene is essential for preventing dental caries, periodontal, and peri-implant diseases. Oral irrigators are adjunctive oral home care aids that may benefit oral health. However, the effects of oral irrigation on oral health, its role in oral home care, and its mechanism of action are not fully understood. A comprehensive search of the literature revealed no existing broad scoping reviews on oral irrigators. Therefore, this study aimed to provide a comprehensive systematic review of the literature on oral irrigation devices and identify evidence gaps.

METHODS

The Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines were utilized to prepare the review. Four databases and eight gray literature sources were searched for English publications across any geographical location or setting.

RESULTS

Two hundred and seventy-five sources were included, predominantly from scientific journals and academic settings. Most studies originated from North America. Research primarily involved adults, with limited studies in children and adolescents. Oral irrigation was safe and well-accepted when used appropriately. It reduced periodontal inflammation, potentially by modulating the oral microbiota, but further research needs to clarify its mechanism of action. Promising results were reported in populations with dental implants and special needs. Patient acceptance appeared high, but standardized patient-reported outcome measures were rarely used. Anti-inflammatory benefits occurred consistently across populations and irrigant solutions. Plaque reduction findings were mixed, potentially reflecting differences in study designs and devices.

CONCLUSIONS

Oral irrigators reduce periodontal inflammation, but their impact on plaque removal remains unclear. Well-designed, sufficiently powered trials of appropriate duration need to assess the clinical, microbiological, and inflammatory responses of the periodontium to oral irrigation, particularly those with periodontitis, dental implants, and special needs. Patient-reported outcome measures, costs, caries prevention, and environmental impact of oral irrigation need to be compared to other oral hygiene aids.

The effectiveness of dental water jet in reducing dental plaque and gingival bleeding in orthodontic patients: A systematic review and meta-analysis of randomized clinical trials

INTRODUCTION

This systematic review and meta-analysis tests the effectiveness of dental water jet (DWJ) with manual toothbrushes (MTB) compared to MTB alone in oral health maintenance in orthodontic patients.

METHODS

Four databases were systematically searched: PubMed, Scopus, Web of Science (WoS) and Cochrane Library until 6 January 2022 using a combination of medical subject heading (MeSH) terms and keywords. Randomized clinical trials (RCTs) were only included and critically appraised using the Cochrane Risk of Bias (ROB) tool. The mean difference (MD) effect measure was calculated using the Mantel-Haenszel statistical test (95% confidence interval [CI]) to compare both study groups (p-value < 0.05).

RESULTS

After reviewing 5881 studies from a systematic search, six were selected for inclusion, with four involved in the quantitative analysis. The risk of bias was low in two studies, moderate in two studies and high in the remaining two studies. The meta-analysis showed a significant improvement in plaque index and bleeding scores in DWJ + MTB group compared MTB alone group in orthodontic patients with generalized gingivitis (MD = -0.75, 95% CI [-1.29, -0.22], p = 0.006) and (MD = -0.17, 95% CI [-0.27, -0.08], p = 0.0003), respectively. However, no significant improvement was detected between both groups in the gingival index.

CONCLUSIONS

The use of DWJ as an adjunctive device in addition to MTB can be an effective strategy for maintaining oral hygiene in orthodontic patients with gingivitis. However, more high-quality RCTs are needed to confirm the findings.

Comparison of the Impact of Two Interdental Cleaning Devices on the Reduction of Bleeding Around Implants

Objective

Purpose: To evaluate the efficacy of water flossing to traditional flossing in lowering the bleeding on probing (BOP) index around dental implants.

Methods and Materials

This single-center, examiner-masked research enrolled patients with implants and randomly allocated them to one of two groups. The research analyzed the effectiveness of manual toothbrushes when used with either string floss or a water flosser.

Results

After 30 days, the main result was a decrease in BOP occurrence. At the outset, neither group had noticeably higher rates of bleeding than the other. While only six of 20 implants in the floss group demonstrated a decrease in BOP after 30 days, 18 of 20 implants in the water flosser group did.

Conclusions

These results demonstrate that the use of water flossers was associated with much less bleeding than that of string floss. The researchers think that water flossing might be a useful addition to the maintenance of dental implants.

A Comparative Review of Water Flossers in Periodontal Therapy

This study investigated the efficacy of water flossers (WFs), devices used to irrigate the interdental and subgingival areas, compared to other interdental care methods, in the management of periodontal disease. A computerized PubMed search was conducted by the author, encompassing the years 1962 to 2023. The year 1962 was selected due to it being the introduction of the first WF. Keywords included "oral irrigator", "efficacy," and "water flossers." The review provided a broad comparative assessment of WFs, rather than an exhaustive detailed article review. We discussed the history and evolution of commercially available WFs and introduced a novel classification system. The research also evaluated the performance of WFs in comparison to traditional and novel interdental care methods, focusing on crucial clinical parameters such as plaque removal efficiency and reduction in gingival inflammation. The results of the study reveal that WFs appear to be superior in the management of periodontal disease and have demonstrated effectiveness in a variety of indices. However, it's worth noting that the author did not statistically analyze any of the data. We identified gaps in the literature and found opportunities for further clinical studies. These findings hold implications for optimal periodontal disease prevention and management, addressing the evolving landscape of oral care practices.

Effectiveness of subgingival irrigation and powered toothbrush as home care maintenance protocol in type 2 diabetic patients with active periodontal disease: A 4-month randomized controlled trial

Background

There is a bidirectional link between diabetes and periodontal disease. Control of active periodontal infection is an essential requisite to maintain optimal oral and systemic health in diabetic patients. The purpose of this study was to evaluate the efficacy of subgingival irrigation and powered toothbrush as home care maintenance protocol in type 2 diabetic patients with active periodontal disease compared to routine oral hygiene.

Materials and Methods

Forty (n = 40) diabetic (HbA1c >7%) patients were enrolled in this parallel, examiner-blind, interventional clinical trial. Patients were randomized into two groups: Group A (sonic toothbrush and irrigation with water twice daily) or Group B (manual toothbrush and mouth rinsing with 0.12% Chlorhexidine gluconate (CHX) twice daily)). All patients received Phase I therapybefore the start of the study. Clinical parameters (plaque index [PI], gingival index [GI], oral hygiene index [OHI], pocket depth [PD], clinical attachment level [CAL], and bleeding index [BI]) were assessed at baseline, 1, 2, and 4 months. Levels of C-reactive protein (CRP), HbA1c, and interleukin (IL)-1 β were assessed at baseline and 4 months only. Verbal and written instructions were provided to each subject specific to their intervention allocation. Descriptive, parametric, and nonparametric analyses were used where appropriate.

Results

Sixteen (n = 16) patients in Group A and fifteen (n = 15) patients in Group B completed the 4-month study. Both groups showed a significant difference in BI, PD, CAL, and HbA1c from baseline to 4 months. There were no differences within groups for OHI, GI, or PI and CRP, IL-1 β. The results are based on an underpowered study due to the drop out of 9 patients reducing the number below the needed 19 patients per group based on the power analysis.

Conclusion

Results from this study provide information for future studies on self-care regimens for individuals living with Type 2 diabetes.

The efficacy of the dental Water Jet, orthodontic, and conventional toothbrushes in plaque removal around orthodontic braces in adolescents: A randomized controlled trial

OBJECTIVES

Orthodontic treatment improves both masticatory function and the aspects of facial esthetics through the correct alignment of the teeth. If oral hygiene is neglected during fixed orthodontic treatment, it may lead to plaque accumulation and gingivitis. The aim of this randomized controlled trial was to evaluate the effectiveness of the dental Water Jet (DWJ), and orthodontic toothbrush (O-TH) in removing dental plaque around the orthodontic braces compared to conventional toothbrush (C-TH) in adolescents.

MATERIALS AND METHODS

This was a three-arm, double-blind, and parallel-group randomized active-controlled trial. Forty-five patients were randomly allocated into three groups: DWJ, the O-TH, and the C-TH (control group). The primary outcome measure was dental plaque accumulation change from the baseline (t0 ) to post-cleaning (t1 ), and plaque scores were recorded using the Orthodontic Plaque Index (OPI). The current clinical trial was registered and approved by Australian New Zealand Clinical Trials Registry (ACTRN12623000524695).

RESULTS

A statistically significant difference was noted in the OPI scores between different time points in the DWJ group, the O-TH group, and the C-TH group (p < .05). However, no significant difference was noted between the groups after the cleaning procedure (p > .05).

CONCLUSION

The level of oral hygiene was not satisfactory in patients undergoing fixed orthodontic treatment. In addition, the efficacy of the DWJ was not superior to O-TH nor to C-TH in plaque removal.

The Efficacy and Safety of Oral Irrigator on the Control of Dental Plaque and Gingivitis: A Randomized, Single-Blind, Parallel-Group Clinical Trial

BACKGROUND

To evaluate the efficacy and safety of oral irrigator (OI) in controlling dental plaque and gingivitis.

METHODS

Ninety participants diagnosed with gingivitis were randomly assigned to two groups, given a toothbrush combined with OI (WaterPik®) (test) or a toothbrush alone (control). The Turesky-Modified Quigley-Hein Plaque Index (T-QH), Modified Gingival Index (MGI), Bleeding Index (BI), and percentage of sites with bleeding on probing (BOP%) were evaluated at baseline, 4 weeks, 8 weeks, and 12 weeks. The full analysis set (FAS) and per-protocol set (PPS) were analyzed. Adverse events were recorded through electronic diaries and examinations.

RESULTS

Of the 90 participants, the efficacy was assessed in the following numbers (FAS/PPS): test (45/33) and control (43/38). Compared with the control, MGI, BI, and BOP% were significantly lower in the test group after 4 weeks (4 weeks: p = 0.017, p = 0.001, and p = 0.001, respectively; 8 weeks and 12 weeks: p < 0.001 for all, FAS); T-QH was significantly lower after 8 weeks (8 weeks: p = 0.033; 12 weeks: p = 0.006, FAS). Transient gingival bleeding may be associated with OI. Self-reported pain and dentin hypersensitivity symptoms were similar between groups.

CONCLUSIONS

As adjuncts to toothbrushing, OI demonstrated significantly better efficacy in controlling dental plaque and gingival inflammation with no substantial safety hazards.

Effect of Nonsurgical Periodontal Therapy on Metabolic Control and Systemic Inflammatory Markers in Patients of Type 2 Diabetes Mellitus with Stage III Periodontitis

Background

A reciprocal relationship is understood to exist between periodontal disease and type 2 diabetes mellitus (T2DM), and this intervention study aimed to evaluate the effects of nonsurgical periodontal therapy (NSPT) on metabolic control, systemic inflammation, and cytokines in patients of T2DM with Stage III periodontitis.

Materials and Methods

Sixty patients of T2DM with Stage III periodontitis were divided equally into two groups: intervention group (IG) and control group. Clinical parameters such as bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) were recorded at baseline and 3 and 6 months, and the serum samples were collected and processed at baseline and 6 months following NSPT to evaluate fasting plasma glucose, Glycosylated hemoglobin (HbA1c), interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α), and high-sensitivity capsule-reactive protein (hs-CRP).

Results

The results indicated a significant improvement in clinical parameters of PPD and CAL 6 months after NSPT (P = 0.005) in both the groups. However, a significant decrease (P < 0.0001) in the TNF-α, hs-CRP, blood glucose, and HbA1c levels was seen after NSPT. On the other hand, an increase in anti-inflammatory cytokine IL-10 was observed after NSPT in the IG. The changes in the pretreatment and posttreatment levels of all clinical, biochemical, and metabolic parameters, were found to be significant in both the groups except BOP.

Conclusion

NSPT effectively improves periodontal condition, systemic inflammatory status, and glycemic control in patients of T2DM with Stage III periodontitis and decreases hs-CRP levels.

Effectiveness of Super Floss and Water Flosser in Plaque Removal for Patients Undergoing Orthodontic Treatment: A Randomized Controlled Trial

Objectives

This study aimed to compare the effectiveness of super floss and water flosser in plaque removal for patients undergoing orthodontic treatment.

Methods

A single-blind, randomized, controlled, parallel clinical trial with a split-mouth protocol was conducted on young adult orthodontic patients who were recruited from Riyadh Specialized Dental Center in Riyadh, Saudi Arabia. The type of floss used was randomly assigned to each side of the oral cavity; Super-Floss® (Oral-B) was used on one side, while the Waterpik® water flosser was used on the other. Patients' plaque level was assessed using Rustogi et al. modified navy plaque index (RMNPI) at baseline and immediately after cleaning.

Results

A total of 62 subjects were screened; however, only 34 subjects were enrolled in the study with an equal number of males and females. Overall, the plaque score was significantly reduced from 0.56 ± 0.35 to 0.13 ± 0.26 in the super floss group and from 0.61 ± 0.35 to 0.13 ± 0.28 in the water flosser group. There was no significant difference between the mean difference of super floss and water flosser (p=0.951). On the other hand, there was no significant difference between both groups in terms of the preintervention plaque score (p=0.379). The water flosser had a greater effect size on plaque removal compared to super floss on distal interproximal surface of the molar tooth with a mean difference of (−0.21, 95% CI: 00.37 to −0.04, p=0.033).

Conclusions

The use of super floss or water flosser as interproximal aids for plaque removal in patients undergoing orthodontic treatment are both effective. Trial registration. ISRCTN, ISRCTN83875016. Registered 12 September 2021-retrospectively registered, https://www.isrctn.com/ISRCTN83875016.

Clinical and biochemical evaluation of oral irrigation in patients with peri-implant mucositis: a randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to compare the efficacy of an oral irrigator and an interdental brush in patients with peri-implant mucositis clinically and biochemically at different time points (at baseline and at the 2nd, 4th, and 12th weeks).

MATERIALS AND METHODS

Forty-five patients with at least one implant with peri-implant mucositis were included in the present study (n = 45). The patients were divided into three groups: oral irrigator + toothbrush (OI group, n = 15), interdental brush + toothbrush (IB group, n = 15), and toothbrush only (control) (C group, n = 15). The modified plaque index (mPlI), modified sulcus bleeding index (mSBI), probing pocket depth (PPD), probing attachment level (PAL), and bleeding on probing (BOP) were recorded at baseline and at the 2nd, 4th, and 12th weeks. The levels of interleukin 1 beta (IL-1β), transforming growth factor-beta (TGF-β), tissue-type plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) were also determined in the peri-implant crevicular fluid samples biochemically.

RESULTS

The mSBI and t-PA at the 2nd week (p = 0.003; p = 0.003); the mPlI, mSBI, BOP, t-PA, and PAI-1 at the 4th week (p < 0.05; p < 0.001; p < 0.001; p = 0.015; p = 0.011); and the mPlI, mSBI, IL-1β, t-PA, and PAI-1 at the 12th week (p < 0.05; p < 0.001; p = 0.013; p < 0.001; p = 0.002) were significantly lower in the OI group compared with those in the C group. Meanwhile, PAI-1 at the 2nd week, mSBI at the 4th week, and t-PA at the 12th week were significantly lower in the OI group compared with those in the IB group (p < 0.001; p = 0.011; p = 0.003). At the 2nd, 4th, and 12th weeks, all other parameters were not statistically different in the three groups.

CONCLUSION

The clinical indexes (such as mSBI and BOP) that play an important role in the diagnosis of peri-implant mucositis showed the lowest means (although limited) in the OI group at all evaluation time points. Moreover, when the clinical and biochemistry results were interpreted altogether, it became apparent that the OI group exhibited similar or more effective results than the IB group in resolving peri-implant mucositis. In light of the foregoing, this study concluded that the use of an oral irrigator can be as effective as an interdental brush in interdental cleaning.

CLINICAL RELEVANCE

In this study, it is suggested that the regular use of an oral irrigator along with a toothbrush could be an appropriate alternative to other oral hygiene products such as dental floss and interdental brush for the management of peri-implant mucositis by preventing the accumulation of dental plaque (NCT03844035).

Effectiveness of Brushing Associated With Oral Irrigation in Maintenance of Peri-Implant Tissues and Overdentures: Clinical Parameters and Patient Satisfaction

Hygiene of implant-supported prostheses and the health of peri-implant tissues are considered to be predictive factors of successful prosthetic rehabilitation. Therefore, the purpose of this study was to evaluate the effectiveness of brushing associated with oral irrigation measured as biofilm-removing capacity, maintenance of healthy oral tissues, and patient satisfaction. A randomized, crossover clinical trial was conducted with 38 patients who wore conventional maxillary complete dentures and mandibular overdentures retained by the O-ring system. The patients were instructed to use the following hygiene methods for 14 days: mechanical brushing (MB; brush and dentifrice, control) and MB with oral irrigation (Waterpik [WP], experimental). Biofilm-removing capacity and maintenance of healthy oral tissues were evaluated by the modified plaque index (PI), gingival index (GI), probing depth (PD), and bleeding on probing index (BP) recorded at baseline and after each method. In parallel, patients answered a specific questionnaire using a visual analog scale after each hygiene method. Data were analyzed by Friedman and Wilcoxon tests (α = .05). The results showed significantly lower PI, GI, PD, and BP after application of the hygiene methods (P < .001) than those observed at baseline. However, no significant difference was found between MB and WP. The responses to the satisfaction questionnaire for both methods showed high mean values for all questions, with no statistically significant difference found between the answers given after the use of MB and WP (P > .05). The findings suggest that WP was effective in reducing PI, GI, PD, and BP indices and provided a high level of patient satisfaction.

A review of T helper 17 cell-related cytokines in serum and saliva in periodontitis

Periodontitis is a chronic inflammatory disease with a complex underlying immunopathology. Cytokines, as molecular mediators of inflammation, play a role in all stages of disease progression. T helper 17 (Th17) cells are thought to play a role in periodontitis. Th17 cell development and maintenance requires a pro-inflammatory cytokine milieu, with many of the cytokines implicated in the pathogenesis of periodontitis. Serum and saliva are easily accessible biofluids which can represent the systemic and local environment to promote the development of Th17 cells. Here we review human clinical studies that investigate IL-1β, IL-4, IL-6, IL-10, IL-17A, IL-17F, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IFN-γ, sCD40L and TNF-α in serum and saliva in periodontitis. We highlight their putative role in the pathogenesis of periodontitis and place them within a wider context of animal and other clinical studies.

Clinical and Microbiological Effects of Weekly Supragingival Irrigation with Aerosolized 0.5% Hydrogen Peroxide and Formation of Cavitation Bubbles in Gingival Tissues after This Irrigation: A Six-Month Randomized Clinical Trial

Introduction

The study investigated the effect of weekly supragingival irrigation with aerosolized 0.5% hydrogen peroxide (H₂O₂) solution as a maintenance periodontal therapy on clinical and microbiological parameters in patients with chronic periodontitis. The other purpose was to investigate whether cavitation bubbles can penetrate not only into periodontitis-damaged tissues but also into ex vivo porcine healthy periodontal tissues.

Materials and Methods

The study included 35 systemically healthy patients with chronic periodontitis (CP). After nonsurgical periodontal debridement (NSPD), all patients were randomized into two groups: the Control group (NSDP alone, n = 18) and the Test group (NSDP plus supragingival irrigation, n = 17). Clinical (Approximal Plaque Index (API), Bleeding Index (BI), and Modified Gingival Index (MGI)) and microbiological (Polymerase Chain Reaction technology (using a micro-IDent® kit)) measurements were performed at the initial time point, 3 months, and 6 months after NSPD. The impact of supragingival irrigation on diseased gingival tissues of CP patients (n = 5) and on ex vivo porcine healthy gingival tissue samples (n = 3) was evaluated to estimate morphological changes in healthy and diseased gingival tissues.

Results

Morphological data revealed that supragingival irrigation caused the formation of cavitation bubbles in diseased gingival tissue of CP patients and in healthy porcine gingival tissues. The decrease in API, BI, and MGI scores after 6 months in the Test group significantly (p ≤ 0.01, p ≤ 0.05, and p ≤ 0.01, respectively) exceeded that in the Control group. Test group patients demonstrated a decrease in periodontal sites showing Pocket Probing Depth > 4 mm and, after 6 months, a statistically significant decrease in the proportion of periopathogenic bacteria.

Conclusion

The effectiveness of mechanical periodontal treatment combined with weekly supragingival irrigation with aerosolized 0.5% H₂O₂ solution on clinical and microbiological parameters of periodontal tissues of periodontitis patients is reliably higher than that of mechanical periodontal debridement alone. It has been found that cavitation bubbles as a result of irrigation with the aerosolized 0.5% hydrogen peroxide solution can form not only in periodontal tissues of periodontitis patients but also in ex vivo porcine healthy gingival tissues.

T helper 17 cell-related cytokines in serum and saliva during management of periodontitis

AIM

T helper (Th)17 cells are implicated in the pathogenesis of periodontitis. This study investigated the effect of periodontal management on fifteen Th17-related cytokines in serum and saliva in periodontitis patients.

MATERIALS AND METHODS

Periodontal parameters, serum and saliva were collected from 40 healthy controls and 54 periodontitis subjects before treatment, and 3-, 6- and 12-months post-treatment. Cytokine concentrations of IL-1β, IL-4, IL-6, IL-10, IL-17A, IL-17F, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IFN-γ, sCD40L and TNF-α were determined by Luminex assay.

RESULTS

IL-1β, IL-6, sCD40L and TNF-α in serum, and IL-1β, IL-6, IL-25 and IL-31 in saliva were significantly higher at baseline compared to health and decreased with treatment. In contrast, serum IL-31 was significantly lower at baseline compared to health and increased with treatment. In addition, salivary IL-10, IL-17A, IL-17F, IL-23, IL-33, IFN-γ and TNF-α also displayed treatment-related reduction. Correlation networks showed that cytokines in saliva displayed a higher number of correlations compared to serum in periodontitis.

CONCLUSION

Treatment generally decreased cytokine concentrations except for serum IL-31 which showed a treatment-related increase. Serum cytokine concentrations may not be reflective of salivary cytokines. Saliva may be a better medium for cytokine detection compared to serum. Serum IL-31 and salivary IL-1β, IL-6, IL-10 and TNF-α were significant predictors for mean probing depth and may be potential biomarkers of interest in the pathogenesis of periodontitis.

Dental water jet efficacy in the plaque control of orthodontic patients wearing fixed appliance: A randomized controlled trial

Background

Different studies assess the role of fixed orthodontic appliances in supragingival plaque accumulation. In patients wearing fixed orthodontic appliances a good management of oral hygiene is required in order to prevent complication like as decay, enamel demineralization, gingivitis, gingival hyperplasia and periodontitis. The aim of this Randomized Controlled Trial (RCT) is to evaluate the efficacy of the use of a DWJ in patients under orthodontic treatment with fixed multibracket appliance.

Material and Methods

The study design was single-blinded RCT with a split mouth protocol. Each patient followed a personal cleaning protocol using a DWJ in addition to traditional brushing only on one side while just brushing on the control side. The side on which was decided to use the DWJ was chosen randomly and the dental hygienist who took the measurements was blind. Plaque and gingival indexes were evaluated at baseline and at one, three and six-months follow-up.

Results

It did not emerge any difference in the plaque and gingival indexes trend between the two groups. Patients initially reported an worsening of the indexes at one month evaluation, then they set at baseline levels at three and six months.

Conclusions

The dental water jet does not improve significantly the efficacy of home oral hygiene in orthodontic patients wearing a multi-bracket fixed appliance. Patients did not show the traditional worsening during the whole orthodontic therapy.

Key words:Dental water jet, fixed orthodontics, plaque index, gingival index.

An Overview of Different Interdental Cleaning Aids and Their Effectiveness

Optimisation of plaque control is essential for the success of non-surgical and surgical periodontal therapy. This cannot be achieved with brushing alone; hence, there is a need for adjunctive interdental cleaning aids. The aim of this paper is to provide an overview of different interdental cleaning aids and review the literature for consensus on their effectiveness. A literature search of articles in English, up to December 2018, was conducted in Pubmed. High-quality flossing is difficult to achieve, and ineffective routine use of floss may not confer significant benefits over brushing alone. Interdental brushes are more effective than brushing as a monotherapy. They are at least as good if not superior to floss in reducing plaque and gingivitis. Although they are effective for patients regardless of their periodontal status (healthy or active), they are especially indicated in periodontal patients where widened embrasures are common. Added benefits include ease of use, patient acceptance, and recontouring of interdental tissues. Rubberpiks do not demonstrate inferiority to conventional interdental brushes. Wooden interdental aids appear to offer no significant advantage over brushing with respect to plaque removal; they may, however, reduce gingival bleeding. Oral irrigators are a promising tool for reducing gingival inflammation, despite minimal changes to plaque levels. For cleaning around dental implants, oral irrigators and interdental brushes are preferred over floss.

Association between Diabetic Retinopathy and Chronic Periodontitis-A Cross-Sectional Study

Periodontal disease (PD), a chronic inflammatory condition characterized by destruction of the supporting tissues of the teeth, increases the risk of complications in diabetics. Diabetic retinopathy (DR) is a microvascular complication of prolonged hyperglycaemia. There appears to be a similarity in the pathogenesis of DR and PD. Hence, this study aimed to investigate the association, if any, between DR and PD, correlate the severity of DR with the severity of PD, and investigate the association between glycated haemoglobin (HbA1c), serum creatinine and periodontal variables. The periodontal status of 200 adult diabetic patients in the age group of 30⁻65 years with varying severity of DR was assessed. Evaluation of the severity of PD was assessed by recording clinical parameters. Haematological investigations including glycated haemoglobin (HbA1c) and serum creatinine were estimated before the initiation of treatment for DR. A statistically significant association between the mean duration of diabetes mellitus (DM) and the severity of DR and PD was found. The severity of PD was directly correlated with the severity of DR. There was a significant association between the levels of HbA1c and serum creatinine and severity of DR and PD. There could be a plausible relationship between DR and PD. Further prospective studies on a larger population with longer follow-ups are required to ascertain whether PD and its severity directly affect the progression and severity of DR.

Periodontal, metabolic, and cardiovascular disease: Exploring the role of inflammation and mental health

Previous evidence connects periodontal disease, a modifiable condition affecting a majority of Americans, with metabolic and cardiovascular morbidity and mortality. This review focuses on the likely mediation of these associations by immune activation and their potential interactions with mental illness. Future longitudinal, and ideally interventional studies, should focus on reciprocal interactions and cascading effects, as well as points for effective preventative and therapeutic interventions across diagnostic domains to reduce morbidity, mortality and improve quality of life.

Effects of nonsurgical periodontal treatment on glycated haemoglobin on type 2 diabetes patients (PARODIA 1 study): a randomized controlled trial in a sub-Saharan Africa population

BACKGROUND

There is a burglar association between diabetes and periodontitis. Many studies has shown that periodontitis treatment can help improving glycemic control in diabetes patients but little evidence of non-surgical treatment benefit is available in sub Saharan african diabetes patients. We aimed to assess the effects of non-surgical periodontal treatment (NSPT) of chronic periodontitis on glycaemic control in poorly controlled type 2 diabetes patients (T2D) in a sub-Saharan Africa urban setting.

METHODS

A total of 34 poorly controlled T2D patients with chronic periodontitis aged 51.4 ± 8.8 years (mean ± SD), with known duration of diabetes of 55.5 ± 42.6 months, and HbA1c of 9.3 ± 1.3% were randomly assigned to two groups. The treatment group (Group 1, n = 17) received immediate ultrasonic scaling, scaling and root planning along with subgingival 10% povidone iodine irrigation, whereas the control group (Group 2, n = 17) was assigned to receive delayed periodontal treatment 3 months later. Pharmacological treatment was unchanged and all participants received the same standardized education session on diabetes management and dental hygiene. The primary outcome was the 3-month change in HbA1c from baseline. Plaque index (PI), gingival bleeding index (GBI), pocket depth (PD), clinical attachment loss (CAL) were also assessed prior to, at 6 and 12 weeks after enrolment.

RESULTS

Two subjects in each group were excluded from the study. Data were analyzed on thirty patients (15 per group). Non-surgical periodontal treatment with education for better dental hygiene (group 1) significantly improved all periodontal parameters whereas education only (group 2) improved only the plaque index among all periodontal parameters. Immediate non-surgical periodontal treatment induced a reduction of HbA1c levels by 3.0 ± 2.4 points from 9.7 ± 1.6% at baseline to 6.7 ± 2.0% 3 months after NSPT, (p ˂ 0.001) but the change was not significant in group 2, from mean 8.9 ± 0.9% at baseline vs 8.1 ± 2.6% after 3 months (p = 0.24).

CONCLUSION

Non-surgical periodontal treatment markedly improved glycaemic control with an attributable reduction of 2.2 points of HbA1c in poorly controlled T2D patients in a sub Saharan setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02745015 Date of registration: July 17, 2016 'Retrospectively registered'.

Effect of supragingival oral irrigation as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients

Aim:

The aim of this study was to evaluate the efficacy of supragingival oral irrigation either with water or different concentrations of chlorhexidine (CHX) digluconate as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients.

Materials and Methods:

Fifty patients were randomly allocated into five groups. Group 1: toothbrushing alone, Group 2: toothbrushing with mouthwash, Group 3: toothbrushing with water irrigation, Group 4: toothbrushing with 0.0075% CHX digluconate (36 mg) supragingival irrigation, and Group 5: toothbrushing with 0.02% CHX digluconate (96 mg) supragingival irrigation. The collected data were subjected to statistical analysis.

Statistical Analysis:

Descriptive data were obtained for all outcome variables and reported as mean ± standard deviation. The Student's t-test, Chi-square test, and one-way analysis of variance (ANOVA) were applied for the statistical evaluation of means and comparisons of proportions, and post hoc Bonferroni test was used for multiple comparisons after the application of the ANOVA test for comparison within the groups.

Results:

When intergroup difference of the mean differences was compared for individuals using toothbrushing along with 0.0075% CHX digluconate irrigation and those using toothbrushing along with 0.02% CHX digluconate irrigation from BL-14, BL-28, and between 14 and 28 days, it was found to be statistically nonsignificant.

Conclusions:

In our study, the CHX digluconate concentration for mouthwash and oral irrigation in addition with toothbrushing was found to be same, i.e., <50 mg for improving the gingival health by reducing gingival inflammation.

Effects on HbA1c in diabetic patients of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment: A systematic review

OBJECTIVE

To assess the effects of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment compared to nonsurgical periodontal treatment alone, on mean glycated hemoglobin (HbA1c) reductions in patients with diabetes.

DATA

Two independent reviewers screened six electronic databases, registers of clinical trials, meeting abstracts and four major dental journals for controlled clinical trials with at least 3-month follow-up.

SOURCES

After duplicates removal, electronic and hand searches yielded 2136 records; 32 full-text articles were independently read by two reviewers. To evaluate the additional effect of antibiotic usage, pooled weighted mean differences and 95% confidence intervals were calculated using fixed and random effects models.

STUDY SELECTION

Twelve studies met the inclusion criteria, nine of which provided data that allowed their inclusion in meta-analyses. The meta-analyses showed no significant effect favouring scaling and root planing (SRP) plus antibiotic for reductions in mean HbA1c (-0.11% [-0.35, 0.13]; 6 studies), and an estimated prediction interval varying from -0.45 to 0.23. There was also no significant effect favouring the adjunctive usage of sub-antimicrobial doxycycline in HbA1c mean reduction (-0.19% [-1.04, 0.67]; 2 studies).

CONCLUSION

Adjunctive use of systemic antibiotic provides no statistically significant benefit in terms of HbA1c improvement in periodontal treatment of patients with diabetes.

CLINICAL SIGNIFICANCE

Adjunctive use of systemic antibiotics associated with nonsurgical periodontal treatment provides no additional benefit in terms of HbA1c of diabetic patients. Clinicians should weigh the trade-off between risks and benefits provided by the use of systemic antibiotics before prescribing them for periodontal disease treatment.

Periodontal and glycemic effects of nonsurgical periodontal therapy in patients with type 2 diabetes stratified by baseline HbA1c

We evaluated the effects of nonsurgical periodontal therapy in 100 patients with type 2 diabetes and chronic periodontitis. The participants were classified as having good (n = 48) or poor (n = 52) glycemic control and were further randomly allocated to receive either scaling and root planning treatment group or no treatment (n = 50 each). The effect of nonsurgical periodontal therapy was compared among diabetic patients with good glycemic control, those with poor glycemic control, and 25 nondiabetic individuals. Periodontal and metabolic status was recorded at baseline, 3 months, and 6 months. In patients receiving treatment, periodontal parameters significantly improved and HbA1c decreased by 10.8%. Improvements in gingival index and bleeding on probing were greater in the nondiabetic participants and the treated patients with good glycemic control than in the treated patients with poor glycemic control (P < 0.05). Regression analysis showed that improvement in periodontal status was independently associated with glycemic improvement. Nonsurgical periodontal therapy improved glycemic control and periodontal health in patients with type 2 diabetes. However, patients with poor baseline glycemic control had less clinical improvement than did those without diabetes and those with good glycemic control.

Effect of Supragingival Irrigation with Aerosolized 0.5% Hydrogen Peroxide on Clinical Periodontal Parameters, Markers of Systemic Inflammation, and Morphology of Gingival Tissues in Patients with Periodontitis

BACKGROUND Various studies have shown that non-surgical periodontal treatment is correlated with reduction in clinical parameters and plasma levels of inflammatory markers. The aim of this study was to evaluate the effect of long-term weekly supragingival irrigations with aerosolized 0.5% hydrogen peroxide as maintenance therapy followed by non-surgical periodontal treatment on clinical parameters, plasma levels of inflammatory markers, and morphological changes in gingival tissues of patients with periodontitis. MATERIAL AND METHODS In total, 43 patients with chronic periodontitis were randomly allocated to long-term maintenance therapy. The patients' periodontal status was assessed using clinical parameters of approximal plaque index, modified gingival index, bleeding index, pocket probing depth, and plasma levels of inflammatory markers (high-sensitivity C-reactive protein and white blood cell count) at baseline and after 1, 2, and 3 years. The morphological status of gingival tissues (immediately after supragingival irrigation) was assessed microscopically. RESULTS Complete data were obtained on 34 patients. A highly statistically significant and consistent reduction was observed in all long-term clinical parameters and plasma levels of inflammatory markers. Morphological data showed abundant spherical bubbles in gingival tissues. CONCLUSIONS 1. The present study showed that non-surgical periodontal treatment with long-term weekly supragingival irrigations with aerosolized 0.5% hydrogen peroxide improved clinical periodontal status and plasma levels of inflammatory markers and may be a promising method in periodontology. 2. We found that supragingival irrigation with aerosolized 0.5% hydrogen peroxide created large numbers of spherical bubbles in gingival tissues.

Changes in diabetes medications in the Diabetes and Periodontal Therapy Trial and their effect on hemoglobin A1c (HbA1c)

OBJECTIVE

Evaluate the effect of medications and medication changes during the Diabetes and Periodontal Therapy Trial (DPTT) on the primary study outcome, namely, change in hemoglobin A1c (HbA1c) at 6months following baseline.

METHODS

The DPTT set strict criteria for changes in diabetes medications. Medication change was defined as: change in dose of any 1 oral hypoglycemic agent by more than two-fold, change in dose of insulin of >10% and/or addition or subtraction of an oral hypoglycemic agent, insulin or non-insulin injectable agents. Comparisons between the treatment (non- surgical periodontal therapy) and control (no therapy) groups used t-tests for continuous variables and chi-square tests for categorical variables, including DPTT defined diabetes medication changes between baseline (BL) and 3month visits and 3- and 6-month visits. Changes in HbA1c were compared across the four medication change categories using ANOVA models, overall and for each treatment group separately.

RESULTS

Baseline medication use was similar between the treatment groups (p>0.40), as were medication changes between BL- 3month visits and 3 and 6month visits (p=0.58). Participants with higher BL HbA1c (>8%) and those taking insulin at BL were more likely to have a change in medication (p=0.03).

CONCLUSIONS

The DPTT had the most rigorous definition of medication changes and medication monitoring of any trial in this field to date. The absence of a significant difference in medication changes between treatment groups may suggest that such changes did not play a role in the negative outcome of the DPTT.

Systemic Antibiotics in Periodontal Treatment of Diabetic Patients: A Systematic Review

Aim

To evaluate the effects of systemic antibiotics in combination with scaling and root planing (SRP) on periodontal parameters, tooth loss and oral health-related quality of life in diabetes patients.

Materials and Methods

Two independent reviewers screened for controlled clinical trials with at least 6-month follow-up in six electronic databases, registers of clinical trials, meeting abstracts and four major dental journals. After duplicates removal, electronic and hand searches yielded 1,878 records; 18 full-text articles were independently read by two reviewers. To evaluate the additional effect of antibiotic usage, pooled weighted mean differences and 95% confidence intervals were calculated using a fixed effects model.

Results

Five studies met the inclusion criteria, four of which were included in meta-analyses. The meta-analyses showed a significant effect favouring SRP plus antibiotic for reductions in mean probing depth (PD) (-0.22 mm [-0.34, -0.11]) and mean percentage of bleeding on probing (BoP) (4% [-7, -1]). There was no significant effect for clinical attachment level gain and plaque index reduction. No study reported on tooth loss and oral health-related quality of life.

Conclusion

Adjunctive systemic antibiotic use in diabetic patients provides a small additional benefit in terms of reductions in mean PD and mean percentage of BoP.

Registration

PROSPERO: CRD42013006389.

Treatment of periodontal disease for glycaemic control in people with diabetes mellitus

BACKGROUND

Glycaemic control is a key issue in the care of people with diabetes mellitus (DM). Periodontal disease is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontal disease. This review updates the previous version published in 2010.

OBJECTIVES

The objective is to investigate the effect of periodontal therapy on glycaemic control in people with diabetes mellitus.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 31 December 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2014, Issue 11), MEDLINE via OVID (1946 to 31 December 2014), EMBASE via OVID (1980 to 31 December 2014), LILACS via BIREME (1982 to 31 December 2014), and CINAHL via EBSCO (1937 to 31 December 2014). ZETOC (1993 to 31 December 2014) and Web of Knowledge (1990 to 31 December 2014) were searched for conference proceedings. Additionally, two periodontology journals were handsearched for completeness, Annals of Periodontology (1996 to 2003) and Periodontology 2000 (1993 to 2003). We searched the US National Institutes of Health Trials Registry (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 DM (T1DM/T2DM) with a diagnosis of periodontitis. Interventions included periodontal treatments such as mechanical debridement, surgical treatment and antimicrobial therapy. Two broad comparisons were proposed:1. periodontal therapy versus no active intervention/usual care;2. periodontal therapy versus alternative periodontal therapy.

DATA COLLECTION AND ANALYSIS

For this review update, at least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials and assessed included trials for risk of bias.Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c).Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing (BOP), clinical attachment level (CAL), gingival index (GI), plaque index (PI) and probing pocket depth (PPD)), cost implications and diabetic complications.

MAIN RESULTS

We included 35 studies (including seven from the previous version of the review), which included 2565 participants in total. All studies used a parallel RCT design, and 33 studies (94%) only targeted T2DM patients. There was variation between studies with regards to included age groups (ages 18 to 80), duration of follow-up (3 to 12 months), use of antidiabetic therapy, and included participants' baseline HbA1c levels (from 5.5% to 13.1%).We assessed 29 studies (83%) as being at high risk of bias, two studies (6%) as being at low risk of bias, and four studies (11%) as unclear. Thirty-four of the studies provided data suitable for analysis under one or both of the two comparisons.Comparison 1: low quality evidence from 14 studies (1499 participants) comparing periodontal therapy with no active intervention/usual care demonstrated that mean HbA1c was 0.29% lower (95% confidence interval (CI) 0.48% to 0.10% lower) 3 to 4 months post-treatment, and 0.02% lower after 6 months (five studies, 826 participants; 95% CI 0.20% lower to 0.16% higher).Comparison 2: 21 studies (920 participants) compared different periodontal therapies with each other. There was only very low quality evidence for the multiple head-to-head comparisons, the majority of which were unsuitable to be pooled, and provided no clear evidence of a benefit for one periodontal intervention over another. We were able to pool the specific comparison between scaling and root planing (SRP) plus antimicrobial versus SRP and there was no consistent evidence that the addition of antimicrobials to SRP was of any benefit to delivering SRP alone (mean HbA1c 0.00% lower: 12 studies, 450 participants; 95% CI 0.22% lower to 0.22% higher) at 3-4 months post-treatment, or after 6 months (mean HbA1c 0.04% lower: five studies, 206 patients; 95% CI 0.41% lower to 0.32% higher).Less than half of the studies measured adverse effects. The evidence was insufficient to conclude whether any of the treatments were associated with harm. No other patient-reported outcomes (e.g. quality of life) were measured by the included studies, and neither were cost implications or diabetic complications.Studies showed varying degrees of success with regards to achieving periodontal health, with some showing high levels of residual inflammation following treatment. Statistically significant improvements were shown for all periodontal indices (BOP, CAL, GI, PI and PPD) at 3-4 and 6 months in comparison 1; however, this was less clear for individual comparisons within the broad category of comparison 2.

AUTHORS' CONCLUSIONS

There is low quality evidence that the treatment of periodontal disease by SRP does improve glycaemic control in people with diabetes, with a mean percentage reduction in HbA1c of 0.29% at 3-4 months; however, there is insufficient evidence to demonstrate that this is maintained after 4 months.There was no evidence to support that one periodontal therapy was more effective than another in improving glycaemic control in people with diabetes mellitus.In clinical practice, ongoing professional periodontal treatment will be required to maintain clinical improvements beyond 6 months. Further research is required to determine whether adjunctive drug therapies should be used with periodontal treatment. Future RCTs should evaluate this, provide longer follow-up periods, and consider the inclusion of a third 'no treatment' control arm.Larger, well conducted and clearly reported studies are needed in order to understand the potential of periodontal treatment to improve glycaemic control among people with diabetes mellitus. In addition, it will be important in future studies that the intervention is effective in reducing periodontal inflammation and maintaining it at lowered levels throughout the period of observation.

Interproximal biofilm removal by intervallic use of a sonic toothbrush compared to an oral irrigation system

BACKGROUND

The purpose of this in-vitro study was to investigate the potential of biofilm removal in interproximal tooth regions using intervallic cleaning with an oral irrigator or a sonic toothbrush.

METHODS

Three-species biofilms (Streptococcus mutans (OMZ 918), Streptococcus oralis SK 248 (OMZ 60), Actinomyces naeslundii (OMZ 745)) were grown on hydroxyapatite discs for 3 days in culture media. Every 24 h, specimens were incubated for 15 min in resazurin solution (i.e., culture medium and 10 % v/v alamarBlue®) to measure the metabolic activity with a fluorescence spectrophotometer in relative fluorescence units (rfu) at baseline. Then, specimens were fixed in interproximal holding devices and underwent treatment with an oral irrigator (WF; Waterpik® Sensonic WP-100E), an active sonic toothbrush (WPa), or an inactive sonic toothbrush (WPi; Waterpik® Sensonic SR-3000E) for 10 s (n = 18/group). Untreated biofilms served as controls (CO). After treatment, bacterial activity was re-measured, and specimens were re-grown in fresh medium for 24 h until next cleaning procedure. Altogether, cleaning was repeated in intervals of three treatment days (d1, d2, d3). After d3, SEM images were taken (n = 8) and CFU was measured (n = 3). Metabolic activity was analyzed for each disc separately, rfu values were averaged for d1 to compare initial biofilm stability, and ratios of baseline and post-treatment values were compared. Results were analyzed using ANOVA with the post-hoc Scheffé test, or Kruskal-Wallis with post-hoc Mann-Whitney test.

RESULTS

Median baseline rfu-values of d1 resulted in 7821.8 rfu (interquartile range = 5114.5). Highest reduction in metabolic activity was recorded significantly for the oral irrigator used for 10 s (residual activity per day d1: WF 17.9 %, WPa 58.8 %, WPi 82.5 %, CO 89.6 %; d2: WF 36.8 %, WPa 85.2 %, WPi 82.5 %, CO 90.0 %; d3: WF 17.2.%, WPa 79.6 %, WPi 96.3 %, CO 116.3 %). SEM images of untreated specimens (CO) and specimens treated with the sonic toothbrush (WPa and WPi) showed huge amounts of biofilm, while oral irrigator-treated specimens (WF) revealed barely any bacteria. CFU data confirmed the graduations between the groups.

CONCLUSIONS

Cleaning of interproximal regions achieved better success with an oral irrigator as compared to the use of a sonic toothbrush. (350/350 words).

Short term effects of periodontal therapy on inflammatory markers in patients with type-2 diabetes

OBJECTIVES

To evaluate the influence of periodontal therapy on glycosylated hemoglobin and fasting blood glucose and serum levels of interleukin (IL)-4, IL-6, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α) in chronic periodontitis (CP) patients with type-2 diabetes mellitus (T2DM) and in controls.

METHODS

A total of 30 periodontal patients, 15 of which were systemically healthy (control group), and 15 were T2DM patients (test group) were included in this study. This prospective study was carried out at Istanbul University, Istanbul, Turkey between February 2011 and December 2013. Plaque index, gingival index, bleeding on probing, periodontal probing depth, and clinical attachment level were assessed and recorded at baseline, one, and 3 months after therapy. Serum samples were collected at the same time-points and analyzed using Luminex assay for the levels of IL-4, IL-6, IL-8, IL-10, and TNF-α. The change in the metabolic control was also monitored.

RESULTS

All clinical parameters were significantly improved after the periodontal therapy in both groups (p less than l0.001). Glycosylated hemoglobin levels were decreased; however, the difference was not significant (p more than 0.05). Fasting blood glucose levels were decreased one month after therapy, and increased at 3 months. Patients with T2DM had significantly higher levels of circulating IL-8 at each time point, and TNF-α (p less than 0.05) at baseline. The IL-4 and IL-10 levels were decreased at one month after therapy (p more than 0.05).

CONCLUSION

Periodontal therapy has limited impact on the serum levels of IL-4, IL-6, IL-8, IL-10, and TNF-α. Metabolic control levels were not influenced by periodontal therapy.

Effect of nonsurgical periodontal treatment on glycosylated hemoglobin in diabetic patients: a systematic review

This review was designed to determine whether non-surgical periodontal treatment is able to reduce serum glycosylated hemoglobin (HbA1c) levels in patients with diabetes mellitus (DM). Several previous reports showed that scaling and root planning (SRP) improve periodontal status in patients with DM, but whether it also improves metabolic control of the disease is unclear. A systematic review was conducted according to the recommendations of the Cochrane Collaboration and PRISMA. A literature search was conducted in October 2012 using three libraries (Cochrane, Web of Knowledge, and Scopus) and the keywords "periodontal disease" and "diabetes mellitus." Only 21 of the articles met the inclusion criteria for this review. A total of 1,454 patients were thus included in this study to evaluate whether periodontal treatment improved serum HbA1c levels. Both the methodological quality and the risk of bias of each study were taken into account using the Jadad scale. Only ten of the included studies had an acceptable-good score of 3-5. Fourteen of the studies reported a significant decrease in serum HbA1c levels (p < 0.05) after periodontal treatment. The remaining seven studies failed to find a significant decrease in serum HbA1c. The findings of this review suggest that the published literature is insufficient and inconclusive to clearly support periodontal treatment as a means to improve serum HbA1c levels in patients with type 1 DM. It also demonstrates the need for homogeneous studies, with larger samples and longer follow-up periods, to properly address this question.

Risk factors of periodontal disease: review of the literature

Objectives. This paper aims to review the evidence on the potential roles of modifiable and nonmodifiable risk factors associated with periodontal disease. Data. Original articles that reported on the risk factors for periodontal disease were included. Sources. MEDLINE (1980 to Jan 2014), PubMed (using medical subject headings), and Google Scholar were searched using the following terms in different combinations: "periodontal disease," "periodontitis," "risk factors," and "causal." This was supplemented by hand-searching in peer-reviewed journals and cross-referenced with the articles accessed. Conclusions. It is important to understand the etiological factors and the pathogenesis of periodontal disease to recognize and appreciate the associated risk factors. As periodontal disease is multifactorial, effective disease management requires a clear understanding of all the associated risk factors.

Effect of periodontal treatment on glycemic control of patients with diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

The aim of the present study was to investigate whether non-surgical periodontal treatment reduces glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels in diabetic patients.

MATERIALS AND METHODS

An electronic search was carried out on MEDLINE (through PubMed interface), EMBASE and the Cochrane Central Register of Controlled Trials. Randomized controlled trials with a minimum of 3 months follow up were included. The risk of bias was assessed for each study. A meta-analysis was carried out to evaluate the effect of non-surgical periodontal treatment on HbA1c and FPG levels. The effect of the adjunctive use of antimicrobials was also assessed.

RESULTS

A total of 15 studies were included. A reduction of -0.38% (95% confidence interval [CI] -0.23 to -0.53) after 3-4 months (P < 0.001) and of -0.31% (95% CI 0.11 to -0.74) after 6 months (P = 0.15) of follow-up was found for HbA1c, favoring the treatment group. Similarly, in treated patients, a significantly greater decrease in FPG was observed in respect to control participants. Such difference amounted to -9.01 mg/dL (95% CI -2.24 to -15.78) after 3-4 months (P = 0.009) and -13.62 mg/dL (95% CI 0.45 to -27.69) after 6 months (P = 0.06) from treatment, respectively. In participants treated with adjunctive antimicrobials, a non-significant increase of HbA1c was observed 3 months after treatment, whereas FPG decreased by 0.27 mg/dL (95% CI 39.56 to -40.11; P = 0.99).

CONCLUSIONS

The meta-analysis showed that non-surgical periodontal treatment improves metabolic control in patients with both periodontitis and diabetes.

Diabetes mellitus and periodontal diseases

A bidirectional relationship between diabetes mellitus (DM) and periodontal diseases (PDs) has been established. It is estimated that patients with poorly controlled DM are 3 times more likely to develop chronic PD compared with normoglycemic individuals despite similar composition in subgingival biofilms. Furthermore, these patients present with increased severity and rapid progression of attachment loss around teeth resulting in edentulism. Treatment of PD results in a modest but significant improvement in glycemic control in patients with DM reflected by a 0.4 % reduction in HbA1c-glycated hemoglobin levels. Compelling evidence from in vitro and animal studies supports a plausible biological explanation for the relationship between the 2 conditions centered on systemic low-grade inflammation. However, the limited number of comparable large randomized clinical trials is reflected in the limited specific guidelines offered by the international organizations for DM and PD regarding the management of the 2 diseases in an individual.

Non-surgical periodontal therapy affects metabolic control in diabetics: a randomized controlled clinical trial

BACKGROUND

Periodontal diseases and diabetes are two common diseases with high prevalence. Many clinicians have accepted the relationship between these two diseases. Some investigators have reported that periodontal treatment may enhance the metabolic control of diabetes. The effects of non-surgical periodontal treatment on metabolic control in people with type 2 diabetes mellitus (DM2) were examined.

METHODS

Forty patients with DM2 and chronic periodontitis [mean age = 50.29 years; mean glycated haemoglobin (HbA1c) = 8.72] were randomly assigned to two groups. The treatment group (n = 22) received full-mouth scaling and root planing, whereas the control group (n = 18) received no periodontal treatment. Gingival index (GI), plaque index (PI), probing pocket depth (PPD), clinical attachment level (CAL), fasting plasma glucose (FPG), HbA1c, total cholesterol (TC), triglyceride (TG) and cholesterol levels were recorded at baseline and compared to data collected three months later.

RESULTS

The groups did not differ in gender ratio, age or clinical parameters [PPD (p = 0.107), CAL (p = 0.888), PI (p = 0.180)] and biochemical markers at baseline [FPG (p = 0.429), HbA1c (p = 0.304), TG (p = 0.486), TC (p = 0.942), LDL (p = 0.856) and HDL (p = 0.881)]. FPG, HbA1c and clinical parameters differed between the treatment and control groups (p = 0.006, 0.003 and 0, respectively). From baseline to follow-up (after three months), HbA1c levels decreased in the treated group (p = 0.003). In the same time period, FPG, GI, PPD and CAL increased in the control group (p = 0.016, 0.0, 0.0 and 0.004, respectively) but HbA1c did not change significantly.

CONCLUSIONS

Non-surgical periodontal therapy could improve metabolic control in diabetic patients.

Effects of non-surgical periodontal treatment on clinical response, serum inflammatory parameters, and metabolic control in patients with type 2 diabetes: a randomized study

BACKGROUND

Scientific evidence on the effects of chronic periodontitis on diabetes mellitus remains inadequate and inconclusive. This intervention study is designed to evaluate the effects of periodontal treatment on clinical response, systemic inflammatory parameters, and metabolic control in patients with Type 2 diabetes.

METHODS

A total of 134 patients were randomly allocated into two treatment groups and one control group. Treatment group 1 underwent non-surgical periodontal treatment at baseline and additional subgingival debridement at the 3-month follow-up. Patients in treatment group 2 received non-surgical periodontal treatment and supragingival prophylaxis at the 3-month follow-up, and those in the control group received no intervention throughout the study. All participants were reexamined at 1.5, 3, and 6 months after initial treatment. At each visit, clinical periodontal examinations were conducted and blood samples were taken to evaluate high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor-α (TNF-α), glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and lipid profiles.

RESULTS

Both treatment groups had a significantly lower hsCRP level after periodontal therapy (P <0.05). Although HbA1c declined significantly in treatment group 2 (P <0.05), the intergroup difference for HbA1c, FPG, TNF-α, and lipid profiles was not statistically significant after therapy (P >0.05).

CONCLUSIONS

Non-surgical periodontal treatment can effectively improve periodontal and circulating inflammatory status. Despite a lack of strong evidence, trends in some results support improved glycemic control after periodontal treatment in patients with diabetes.

Diabetes mellitus and periodontitis: a tale of two common interrelated diseases

Diabetes mellitus (a group of metabolic disorders characterized by hyperglycemia) and periodontitis (a microbially induced inflammatory disorder that affects the supporting structures of teeth) are both common, chronic conditions. Multiple studies have demonstrated that diabetes mellitus (type 1 and type 2) is an established risk factor for periodontitis. Findings from mechanistic studies indicate that diabetes mellitus leads to a hyperinflammatory response to the periodontal microbiota and also impairs resolution of inflammation and repair, which leads to accelerated periodontal destruction. The cell surface receptor for advanced glycation end products and its ligands are expressed in the periodontium of individuals with diabetes mellitus and seem to mediate these processes. The association between the two diseases is bidirectional, as periodontitis has been reported to adversely affect glycemic control in patients with diabetes mellitus and to contribute to the development of diabetic complications. In addition, meta-analyses conclude that periodontal therapy in individuals with diabetes mellitus can result in a modest improvement of glycemic control. The effect of periodontal infections on diabetes mellitus is potentially explained by the resulting increase in levels of systemic proinflammatory mediators, which exacerbates insulin resistance. As our understanding of the relationship between diabetes mellitus and periodontitis deepens, increased patient awareness of the link between diabetes mellitus and oral health and collaboration among medical and dental professionals for the management of affected individuals become increasingly important.

Periodontitis and risk of diabetes mellitus

Diabetes mellitus (DM) is a complex disease with varying degrees of systemic and oral complications. The periodontium is also a target for diabetic damage. Diabetes is a pandemic in both developed and developing countries. In recent years, a link between periodontitis and diabetes mellitus has been postulated. The oral cavity serves as a continuous source of infectious agents that could further worsen the diabetic status of the patient and serve as an important risk factor deterioration of diabetes mellitus. The present review highlights the relationship between diabetes mellitus and periodontitis. The potential mechanisms involved in the deterioration of diabetic status and periodontal disease are also discussed.

The effect of full-mouth tooth extraction on glycemic control among patients with type 2 diabetes requiring extraction of all remaining teeth: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Several studies have shown that periodontitis can complicate the severity of diabetes by worsening the degree of glycemic control. The purpose of this study was to determine the effect of full-mouth tooth extraction on glycemic control among type 2 diabetic patients.

MATERIAL AND METHODS

A total of 58 patients with type 2 diabetes mellitus and advanced periodontitis who were requiring extraction of all remaining teeth were randomized consecutively into treatment (full-mouth tooth extraction) and control groups (no treatment). Eight patients were lost to follow-up or reported use of antibiotics, leaving 50 patients to be included in the analysis. All patients had all their remaining teeth in a hopeless condition. Relevant data were collected, and glycosylated hemoglobin (HbA(1c) ) and fasting blood glucose levels were measured at baseline and at follow-up times of 3 and 6 mo.

RESULTS

At baseline, the mean (SD) HbA(1c) level was 8.6% (1.24) in the treatment group and 7.7% (0.87) in the control group. In the treatment group, the mean HbA(1c) level decreased significantly from 8.6% at baseline to 7.4% after 3 mo of denture treatment, and continued to decrease to 7.3% after 6 mo. In the control group, the mean HbA(1c) decreased from 7.7% at baseline to 7.5% after 3 mo, and remained almost the same after 6 mo. After adjusting for the baseline HbA(1c) , the mean reduction in HbA(1c) after 3 mo in the treatment group [1.23% (0.79)] was significantly higher than the mean reduction in the control group [0.28% (0.87)].

CONCLUSION

Full-mouth tooth extraction resulted in an improvement in glycemic control among diabetic patients. Large-scale multicentre clinical trials are needed to confirm the current evidence.

Treatment of periodontal disease for glycaemic control in people with diabetes

BACKGROUND

Glycaemic control is a key issue in the care of people with diabetes mellitus (DM). Some studies have suggested a bidirectional relationship between glycaemic control and periodontal disease.

OBJECTIVES

To investigate the relationship between periodontal therapy and glycaemic control in people with diabetes and to identify the appropriate future strategy for this question.

SEARCH STRATEGY

A comprehensive approach was adopted employing handsearching; searching of electronic databases including the Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, ZETOC, ISI Web of Knowledge and LILACS; contact with appropriate non-English language healthcare professionals; authors and organisations. The final date for searching for studies was 24th March 2010.

SELECTION CRITERIA

This review studied randomised controlled trials of people with Type 1 or 2 diabetes mellitus (DM) with a diagnosis of periodontitis. Suitable interventions included mechanical periodontal therapy with or without adjunctives and oral hygiene education.

DATA COLLECTION AND ANALYSIS

The titles and abstracts of 690 papers were examined by two review authors independently. Ultimately, seven studies were included and 19 excluded after full text scrutiny. All trials were assessed for risk of bias.

MAIN RESULTS

Three studies had results pooled into a meta-analysis. The effect for the mean percentage difference in HbA1c for scaling/root planing and oral hygiene (+/- antibiotic therapy) versus no treatment/usual treatment after 3/4 months was -0.40% (95% confidence interval (CI) fixed effect -0.78% to -0.01%), representing a statistically significant reduction in HbA1c (P = 0.04) for scaling/root planing. One study was assessed as being at low risk of bias with the other two at moderate to high risk of bias. A subgroup analysis examined studies without adjunctive antibiotics -0.80% (one study: 95% CI -1.73% to 0.13%; P = 0.09), with adjunctive antibiotics in the test group -0.36% (one study: 95% CI -0.83% to 0.11%; P = 0.14), and with antibiotics in both test and control groups after 3/4 months -0.15% (one study: 95% CI -1.04% to 0.74%; P = 0.74).

AUTHORS' CONCLUSIONS

There is some evidence of improvement in metabolic control in people with diabetes, after treating periodontal disease. There are few studies available and individually these lacked the power to detect a significant effect. Most of the participants in the study had poorly controlled Type 2 DM with little data from randomised trials on the effects on people with Type 1 DM.Improving periodontal health is an important objective in itself. However, in order to understand the potential of this treatment to improve glycaemic control among people with diabetes, larger, carefully conducted and reported studies are needed.

Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis

OBJECTIVE

There is growing evidence that periodontitis may affect general health. This study was assigned to explore the robustness of observations that periodontal therapy leads to the improvement of glycemic control in diabetic patients.

RESEARCH DESIGN AND METHODS

A literature search (until March 2009) was carried out using two databases (MEDLINE and the Cochrane Library) with language restriction to English. Selection of publications was based on 1) original investigations, 2) controlled periodontal intervention studies where the diabetic control group received no periodontal treatment, and 3) study duration of > or =3 months.

RESULTS

Screening of the initial 639 identified studies and reference checking resulted in five suitable articles. A total of 371 patients were included in this analysis with periodontitis as predictor and the actual absolute change in A1C (DeltaA1C) as the outcome. The duration of follow-up was 3-9 months. All studies described a research population of type 2 diabetic patients in whom glycemic control improved after periodontal therapy compared with the control group (range DeltaA1C: Delta-1.17 up to Delta-0.05%). The studies in a meta-analysis demonstrated a weighted mean difference of DeltaA1C before and after therapy of -0.40% (95% CI -0.77 to -0.04%, P = 0.03) favoring periodontal intervention in type 2 diabetic patients. Nevertheless, this improvement in %A1C must be interpreted with care due to limited robustness as evidenced by heterogeneity among studies (59.5%, P = 0.04).

CONCLUSIONS

The present meta-analysis suggests that periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients for at least 3 months.

Effect of periodontal treatment on metabolic control, systemic inflammation and cytokines in patients with type 2 diabetes

OBJECTIVE

The aim of this study was to investigate the effect of periodontal therapy on the circulating concentration of high-sensitivity capsule-reactive protein (hs-CRP), fibrinogen (FIB), interleukin (IL)-4, IL-6, IL-8, IL-10 and tumour necrosis factor-alpha (TNF-alpha) and on the metabolic control in type 2 diabetes mellitus (T2DM) patients.

MATERIAL AND METHODS

Twenty-three T2DM patients with chronic periodontitis were enrolled in this study. Periodontal clinical parameters, namely visible plaque index, gingival bleeding index, bleeding on probing, probing depth and clinical attachment levels, were evaluated. Blood samples for plasma were collected and assessed for the levels of hs-CRP, FIB, IL-4, IL-6, IL-8, IL-10 and TNF-alpha. The glycated haemoglobin (HbA(1c)) and fasting plasma glucose were also measured. All parameters were evaluated before and 3 months after non-surgical periodontal therapy.

RESULTS

All clinical parameters were significantly improved 3 months after the periodontal therapy. A univariate comparison showed a tendency towards a decrease of the measured biomarkers, most pronounced for TNF-alpha and FIB, after therapy. Periodontal treatment also reduced HbA(1c) and hs-CRP levels, albeit not significantly.

CONCLUSIONS

The clinically successful non-surgical periodontal therapy tended to reduce systemic inflammation and the concentration of some circulating cytokines.