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

The effect of antimicrobial photodynamic therapy on periodontal disease and glycemic control in patients with type 2 diabetes mellitus

OBJECTIVES

This study is aimed at determining the effect of concomitant antimicrobial photodynamic therapy (aPTD) on periodontal disease and glycaemic control in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Twenty-four patients with T2DM were enrolled in the study. Periodontal clinical parameters were assessed by measuring probing pocket depth (PPD), clinical attachment loss (CAL), gingival recession (GR), full-mouth bleeding score (FMBS), full-mouth plaque score (FMPS), and full-mouth sulcus bleeding score (FMSBS). Glycated haemoglobin A1c (HbA1c) was measured. To determine the presence of the following periodontal pathogenic bacteria, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola, subgingival plaque samples were taken from two periodontal pockets per jaw with the greatest PPD using paper tips. Patients were randomly divided into the test and control group. In the test group, full-mouth disinfection was performed in combination with aPTD. In the control group, only full-mouth disinfection was performed.

RESULTS

The results showed an improvement in periodontal clinical parameters in both groups. The difference between the groups in favour of the test group was statistically significant for BOP. The HbA1c level decreased in both groups. The difference was not statistically significant. The results of the microbiological analysis suggest that the presence of periodontal pathogenic bacteria is lower with additional antimicrobial photodynamic therapy with statistically significant difference for T. forsythia.

CONCLUSIONS

Additional aPDT causes a significant reduction in BoP in the proportion of positive sites for periodontal pathogens.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05816941.

CLINICAL RELEVANCE

aPTD is a noninvasive adjunctive therapy that can positively influence the periodontal treatment outcome.

A novel adiponectin receptor agonist (AdipoAI) ameliorates type 2 diabetes-associated periodontitis by enhancing autophagy in osteoclasts

BACKGROUND AND OBJECTIVE

Type 2 diabetes (T2D)-associated periodontitis is severe and refractory in many cases. Considered an inflammatory disease, T2D predisposes to periodontitis by increasing whole-body inflammation. One mechanism of increased inflammation is thatT2D is mediated by loss of production or function of the anti-inflammatory hormone adiponectin. In our previous report, AdipoRon, an adiponectin receptor agonist, and AdipoAI, a newly discovered, more specific agonist, attenuated T2D-associated inflammation by inhibiting osteoclastogenesis and LPS-induced endotoxemia. Autophagy plays an important role during osteoclast differentiation and function. The impact of AdipoAI on osteoclast function and autophagy involved in osteoclastogenesis is not known. Here, we compare AdipoRon and AdipoAI potency, side effects and mechanism of action in T2D-associated periodontitis.

METHODS

The RAW 264.7 cell line was used for in vitro studies. We analyzed the potential cytotoxicity of AdipoAI using the CCK-8 assay. The anti-osteoclastogenic potential of AdipoAI was studied by real-time qPCR and tartrate-resistant acid phosphatase staining. The actions of AdipoAI involved in autophagy were tested by real-time qPCR, western blot and immunofluorescence staining. In the diet-induced obesity model of T2D, we investigated the impact of AdipoAI on fasting blood glucose, alveolar bone loss, and gingival inflammation in mice with experimental periodontitis.

RESULTS

AdipoRon inhibited osteoclastogenesis and AdipoAI inhibited osteoclastogenesis at lower doses than AdipoRon without any cytotoxicity. In DIO mice with experimental periodontitis, AdipoAI reduced mouse body weight in 14 days, reducing fasting glucose levels, alveolar bone destruction, osteoclast number along the alveolar bone surface, and decreased the expression of pro-inflammatory factors in periodontal tissues. AdipoAI and AdipoRon also enhanced LC3A/B expression when cultured with RANKL.3-Methyladenine, a known autophagy inhibitor, decreased LC3A/B expression and reversed the inhibition of osteoclastogenesis during AdipoAI treatment.

CONCLUSIONS

Our results demonstrate that AdipoAI ameliorates the severity of T2D-associated periodontitis by enhancing autophagy in osteoclasts at lower doses than AdipoRon without demonstrable side effects. Thus, AdipoAI has pharmaceutical potential for treating diabetes-associated periodontal disease.

Adjunctive Er:YAG laser in non-surgical periodontal therapy of patients with inadequately controlled type 2 diabetes mellitus: A split-mouth randomized controlled study

BACKGROUND AND OBJECTIVE

Limited studies are available comparing the outcomes of non-surgical periodontal therapy (NSPT) with or without adjunctive Er:YAG laser (ERL) in patients with type 2 diabetes mellitus (T2DM). This study evaluated the effects of ERL adjunctive NSPT on single-rooted teeth of inadequately controlled T2DM patients with periodontitis.

METHODS

Twenty-two inadequately controlled T2DM participants with periodontitis were recruited. Adopting a double-blinded split-mouth design and under block randomization, we investigated the effects of ERL in calculus removal then degranulation mode, or a sham treatment, adjunct NSPT, which included two visits of full-mouth root surface debridement delivered within 4-10 days, to test or control single-rooted teeth (Wuxi Stomatology Hospital, trial 2017-016). We followed periodontal parameters (plaque %, bleeding on probing [BOP] %, probing pocket depth [PPD], probing attachment level [PAL]) and selected systemic parameters (fasting plasma glucose [FPG], glycosylated hemoglobin [HbA1c%], high sensitivity C-reactive protein) at baseline, one, three, and six months after periodontal treatment.

RESULTS

The study was completed as planned. Periodontal parameters, FPG and HbA1c% of the 22 participants appeared significantly improved at six months (p < 0.001). The 44 ERL treated, compared to 44 sham treated single-rooted teeth exhibited significant improvement in BOP, mean PPD, and mean PAL at various postoperative follow-up time points (effect size ≥0.44; p < 0.001). No adverse event was reported.

CONCLUSION

Periodontal treatment outcomes in the T2DM patients with inadequate glycemic control were better in the single-rooted teeth received ERL adjunct NSPT. Further studies are warranted to confirm the observations reported in this short-term clinical study.

Polymorphisms and haplotypes in the Interleukin 17 Alfa gene: potential effect of smoking habits in the association with periodontitis and type 2 diabetes mellitus

Few studies evaluate interrelationships between periodontitis (P) and Type 2 Diabetes Mellitus (T2DM). The aim of this study is to investigate the genetic susceptibility to periodontitis alone, or concomitant with T2DM (as comorbidities), analyzing single nucleotide polymorphisms (SNPs) in the Interleukin 17 alpha (IL17A) gene, considering the biochemical profile and smoking habits on the subjects' periodontal status. We investigated 879 individuals divided into: T2DM subjects also affected by severe or moderate periodontitis (T2DM-P, n = 199); non-diabetics with severe or moderate periodontitis (PERIODONTITIS, n = 342); and healthy subjects (HEALTHY, n = 338). Subjects underwent complete periodontal examination, history of smoking habits, glycemic and lipid biochemical evaluation. DNA from buccal cells was utilized to genotype the SNPs rs2275913, rs3819024 and rs10484879. The impact of the subjects' biochemical profile was analyzed in their periodontal status. Each SNP was analyzed independently, and as haplotypes, by multiple logistic regressions, adjusted for covariates, and also stratifying the groups by age, sex and smoking habits. Independently of the periodontitis degree, poorly-controlled T2DM subjects showed worse glycemic and lipid profile. Multiple logistic regressions demonstrated that smokers and former-smokers carrying the GG genotype of rs3819024 seemed to have higher risk for T2DM-Periodontitis (OR = 6.33; 95% CI = 1.26-31.77, p = 0.02), and mainly for T2DM alone (OR = 5.11; 95% CI = 1.37-19.06, p = 0.01), than never smokers. We found the potential effect of smoking habits in the association of IL17A-rs3819024-GG with diseased phenotypes. Because the observed wide confidence intervals, further studies enrolling larger populations, and SNPs' functional evaluations are needed to better understand our findings.

Hyperglycemia Induces Osteoclastogenesis and Bone Destruction Through the Activation of Ca2+/Calmodulin-Dependent Protein Kinase II

Hyperglycemia induces osteoclastogenesis and bone resorption through complicated, undefined mechanisms. Ca²⁺/calmodulin-dependent protein kinase II (CaMKII) promotes osteoclastogenesis, and could be activated by hyperglycemia. Here, we investigated whether CaMKII is involved in hyperglycemia-induced osteoclastogenesis and subsequent bone resorption. Osteoclast formation, bone resorption, CaMKII expression and phosphorylation were measured under high glucose in vitro and in streptozotocin-induced hyperglycemia rats with or without CaMKII inhibitor KN93. The results showed that 25 mmol/L high glucose in vitro promoted cathepsin K and tartrate-resistant acid phosphatase expression (p < 0.05) and osteoclast formation (p < 0.01) associated with enhancing β isoform expression (p < 0.05) and CaMKII phosphorylation (p < 0.001). Hyperglycemia promoted the formation of osteoclasts and resorption of trabecular and alveolar bone, and inhibited sizes of femur and mandible associated with enhanced CaMKII phosphorylation (p < 0.001) in rats. All these changes could be alleviated by KN93. These findings imply that CaMKII participates not only in hyperglycemia-induced osteoclastogenesis and subsequent bone resorption, but also in the hyperglycemia-induced developmental inhibition of bone.

A study on the change in HbA1c levels before and after non-surgical periodontal therapy in type-2 diabetes mellitus in generalized periodontitis

Aim:

The aim of this study was to evaluate and investigate changes in HbA1c levels before and after non-surgical periodontal therapy in type-2 diabetes mellitus patients with generalized periodontitis.

Materials and Methods:

A statistically significant number of type-2 diabetes mellitus subjects diagnosed with chronic generalized periodontitis were included in the study. The selected subjects were randomly allocated to 2 groups. Group 1: Control group: Subjects who received only scaling and root planning. Group 2: Test group: Subjects received antibiotic coverage with non-surgical periodontal therapy (scaling and root planning). Clinical parameters included plaque index, gingival index, PRO MIG pocket depth, and clinical attachment level. In addition, the metabolic parameters were recorded at the same time intervals, which included fasting blood sugar, random blood sugar, and HbA1c levels.

Statistical Analysis:

ANOVA test was applied to the parameters.

Results:

HbA1c more significantly reduced by test group compared to the other group. Conclusion: there is definitely a positive effect of nonsurgical on HbA1c levels in type 2 diabetes mellitus. This point levels significantly reduced after conventional non-surgical periodontal therapy.

Conclusion:

There is definitely a positive effect of non-surgical periodontal therapy on HbA1c levels in type 2 diabetes patients with chronic periodontitis.

Diabetes mellitus and periodontal disease: awareness and practice among doctors working in public general out-patient clinics in Kowloon West Cluster of Hong Kong

BACKGROUND

Diabetes mellitus (DM) and periodontitis are very common and they interact with each other bidirectionally. This survey studied public primary care doctors on their awareness of this bidirectional relationship and their corresponding practice.

METHODS

All Family Medicine doctors in Kowloon West Cluster, Hospital Authority were invited to a cross-sectional questionnaire survey. Results were analyzed statistically.

RESULTS

One hundred sixty-eight questionnaires were sent out, 143 were returned (response rate 85.1%). One hundred forty valid questionnaires were analyzed. Ninety-two percent of participants were aware of a relationship between DM and periodontal disease and this awareness was not associated with their years of experience, training status and personal oral health behavior. Ninety percent knew the effect of poor DM control on periodontal disease but only 76% were aware of the reverse effect of periodontal disease on DM. The difference was statistically significant (p = 0.002, Related-samples Sign Test). In clinical practice on DM patients, only 5.7% asked dental history often (defined as 50% patients or above), 7.1% examined their mouths often and 12.1% recommended them to see dentist often. Logistic regression showed that awareness factors had no association with periodontology related clinical practice whereas clinical experience, being a Family Medicine specialist and personal interdental cleaning habit were linked with more positive practice.

CONCLUSIONS

A high proportion of doctors in the study were aware of the relationship between DM and periodontal disease. However, this did not appear to influence their practice. Further measures among doctors and patients to promote comprehensive management of DM and periodontal disease should be explored.

The association between Type 1 diabetes mellitus and periodontal diseases

BACKGROUND/PURPOSE

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease affecting oral health. Evidence shows possible association between T1DM and periodontal diseases (PDs). We conducted a nationwide population-based study in Taiwan, with a 14-year follow-up to investigate the risk of PDs in T1DM patients.

METHODS

We used data from the National Health Insurance Research Database in Taiwan. The T1DM cohort was identified with newly diagnosed T1DM from 1998 to 2011. The non-T1DM cohort was frequency matched with the T1DM cohort. Participants comprised 4248 patients in the T1DM cohort and 16992 persons in the non-T1DM cohort.

RESULTS

The T1DM patients showed an increased risk of PDs compared to non-T1DM individuals [adjusted hazard ratio (aHR) = 1.45]. T1DM patients who visited the emergency room more than twice per year had a higher aHR of 13.0 for developing PDs. The aHR for PDs was 13.2 in the T1DM patients who had been hospitalized more than twice per year.

CONCLUSION

T1DM patients are at higher risk of developing PDs than non-T1DM individuals. Our results further showed that the number of T1DM interventions; that is, annual emergency visits and hospitalizations were associated with increased the risk of developing PDs.

Does diabetes increase the risk of periodontitis? A systematic review and meta-regression analysis of longitudinal prospective studies

AIM

Even though the association between diabetes and periodontitis is taken for granted, results on this association are conflicting within the literature. This systematic review assessed whether poorly controlled diabetes was associated with periodontitis onset or progression.

METHODS

Electronic searches were performed in PubMed, Scopus and Embase databases. Hand search was carried out in the reference list of all articles included. Gray literature was investigated with a Google Scholar search. Prospective longitudinal studies on the association between diabetes and periodontitis were considered for this review. Studies should have presented at least two measurements of periodontal conditions over time. Data on study design, crude and adjusted estimates were collected. We used meta-analysis to estimate the pooled effect of hyperglycemia in people with diabetes on periodontitis onset or progression. Meta-regression and subgroup analyses were employed to investigate potential sources of heterogeneity between studies.

RESULTS

Thirteen studies matched the inclusion criteria, comprising 49,262 individuals, including 3197 diagnosed with diabetes. Meta-analyses of adjusted estimates showed that diabetes increased the risk of incidence or progression of periodontitis by 86% (RR 1.86 [95% CI 1.3-2.8]). However, there is scarce information on the association between diabetes and periodontal destruction.

CONCLUSIONS

This study provides evidence that diabetes is associated with increased risk of periodontitis onset and progression in adults. Upcoming prospective longitudinal studies ought to overcome methodological caveats identified in this review.

The Effect of Diabetes Mellitus Type I on Periodontal and Dental Status

INTRODUCTION

Diabetes mellitus type I is a chronic metabolic disease with an autoimmune origin. The initial manifestations mainly appear during childhood and its prevalence is on the rise in many countries. Some of the complications of diabetes mellitus are problems related to oro-dental structures and periodontal diseases.

AIM

The present study was undertaken to evaluate the relationship between diabetes mellitus type I and dental and periodontal status in Tehran, Iran.

MATERIALS AND METHODS

This cross-sectional study was carried out on 50 patients with diabetes mellitus type I who were under treatment in the Diabetic Patients' Center in Tehran and 50 healthy individuals who did not have diabetes, all recruited from schools. The subjects were divided into two age groups of 6-12 and 13-18 years. In test group, HbA1c (glycosylated haemoglobin) level of the patients was collected from the medical records of Association of Diabetic Patients. To make sure that the control subjects did not suffer from diabetes mellitus, their blood glucose was measured with the Glucocard 01 blood glucose monitoring kit (GT-1920, Japan). The periodontal and dental status were assessed using dmft/DMFT (Decayed, Missing, Filled Permanent Teeth), GI (Gingival Index), PPD (Periodontal Pocket Depth), PI (Plaque Index) and CI (Calculus Index). The data obtained from each group were compared statistically using the Mann-Whitney test and Kruskal Wallis Test.

RESULTS

There was increase in PPD, GI and DMFT values with aging, with no significant differences between the diabetic and non-diabetic groups. PI and DMFT not only increased with aging but also were higher in both age groups in patients with diabetes compared to healthy subjects (p<0.05). GI was higher only in the 13-18 year age group in diabetic patients (p<0.01). There was no relation between the HbA1c (glycosylated haemoglobin) level, and periodontal indices (p<0.09).

CONCLUSION

It appears that patients with diabetes mellitus type I are more susceptible to periodontal diseases and tooth loss and such problems might be aggravated with aging.

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.

Periodontal treatment and glycaemic control in patients with diabetes and periodontitis: an umbrella review

BACKGROUND

Studies suggest that non-surgical periodontal treatment improves glycaemic control in patients with diabetes and periodontitis. The aim of this umbrella review is to summarize the effects of periodontal treatment on glycaemic control in patients with periodontitis and diabetes.

METHODS

A systematic review of systematic reviews with or without meta-analysis published between 1995 and 2015 was performed. Three independent reviewers assessed for article selection, quality and data extraction.

RESULTS

Thirteen (13) systematic reviews/meta-analysis were included for qualitative synthesis. A reduction (0.23 to 1.03 percentage points) in the levels of HbA1c at 3 months after periodontal intervention was found. This reduction was statistically significant in 10/12 meta-analysis. One review with sufficiently large samples found a non-significant reduction (-0.014 percentage points; 95% CI -0.18 to 0.16; p = 0.87). Only three studies separated the use of adjunctive antibiotics and found a reduction of 0.36 percentage points but the difference was not statistically significant.

CONCLUSIONS

Highly heterogeneous short-term studies with small sample size suggest that periodontal treatment could help improve glycaemic control at 3 months in patients with type 2 diabetes and periodontitis. However, longer term studies having sufficient sample size do not provide evidence that periodontal therapy improves glycaemic control in these patients.

Nonsurgical periodontal therapy with/without diode laser modulates metabolic control of type 2 diabetics with periodontitis: a randomized clinical trial

In order to evaluate whether nonsurgical periodontal treatment with/without diode laser (DL) decontamination improves clinical parameters, the levels of IL-1β, IL-6, IL-8, intercellular adhesion molecule (ICAM), and vascular cell adhesion molecule (VCAM) in gingival crevicular fluid and metabolic control (HbA1c) in chronic periodontitis (CP) patients with diabetes mellitus type 2 (DM2). Sixty patients with DM2 and CP were randomly assigned into two groups to receive scaling and root planing (SRP, n = 30) or SRP followed by diode laser application (SRP + DL, n = 30). Clinical periodontal and gingival crevicular fluid (GCF) parameters were assessed at baseline, 1, and 3 months after periodontal treatment. HbA1c levels were evaluated at baseline and 3 months post-therapy. Total amounts of cytokines and molecules were analyzed by ELISA. Nonsurgical periodontal treatment with/without DL appeared to improve clinical, biochemical parameters, and glycemic control in DM2 patients (BMI < 25 kg/m(2)) with CP. The SRP + DL group provided better reductions in probing depth (PD) and clinical attachment level (CAL) parameters compared to the SRP group (P < 0.05). Significant reductions were found in the total amounts of GCF levels of IL-1, IL-6, IL-8, ICAM, and VCAM after treatment (P < 0.05). HbA1c levels decreased significantly at 3 months after treatment (P < 0.05). SRP + DL reduced HbA1c levels more significantly compared to SRP alone (0.41 vs. 0.22 %, P < 0.05). SRP, especially in combination with DL, shows improvement of glycemic control for DM2 patients with CP.

Relationship between diabetes and periodontal infection

Periodontal disease is a high prevalent disease. In the United States 47.2% of adults ≥ 30 years old have been diagnosed with some type of periodontitis. Longitudinal studies have demonstrated a two-way relationship between diabetes and periodontitis, with more severe periodontal tissue destruction in diabetic patients and poorer glycemic control in diabetic subjects with periodontal disease. Periodontal treatment can be successful in diabetic patients. Short term effects of periodontal treatment are similar in diabetic patients and healthy population but, more recurrence of periodontal disease can be expected in no well controlled diabetic individuals. However, effects of periodontitis and its treatment on diabetes metabolic control are not clearly defined and results of the studies remain controversial.

Efficacy of nonsurgical periodontal therapy on glycaemic control in type II diabetic patients: a randomized controlled clinical trial

PURPOSE

Diabetes and periodontal disease are two common diseases with high prevalence rates. Recent evidence has shown a bidirectional relationship between diabetes and periodontitis. The aim of this study was to investigate the effects of nonsurgical periodontal therapy on glycemic control in type 2 diabetes mellitus patients.

METHODS

Sixty subjects aged 35-45 years with blood sugar controlled by oral hypoglycaemic agents were randomly divided equally among 3 groups: group A (scaling, mouthwash, and brushing), group B (mouthwash and brushing), and group C (brushing only). Glycated haemoglobin (HbA1c), fasting blood sugar (FBS), probing pocket depth (PPD), gingival index (GI), plaque index (PI), and the relevant drug history were recorded at baseline and after 3 months of intervention. Comparison of the mean difference among the variables was performed by parametric and nonparametric tests, which were further evaluated using multiple regression analysis.

RESULTS

The mean differences between the PPD, FBS, HbA1c, GI, and PI in groups A and B were found to be statistically significant (P<0.001). Multiple regression analysis in group A showed that out of all the independent variables, GI and frequency of drug administration independently (b=0.3761 and b=0.598) showed a significantly greater impact on HbA1c (R(2)=0.832, P<0.05).

CONCLUSIONS

Nonsurgical periodontal therapy can effectively decrease HbA1c levels in type 2 diabetes mellitus patients on medication.

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.

Periodontal disease and diabetes

Diabetes is considered to be a genetically and environmentally based chronic metabolic and vascular syndrome caused by a partial or total insulin deficiency with alteration in the metabolism of lipids, carbohydrates and proteins culminating with different manifestations in different organisms. In humans hyperglycemia is the main consequence of defects in the secretion and/or action of insulin, and its deregulation can produce secondary lesions in various organs, especially kidneys, eyes, nerves, blood vessels and immune systems. Periodontal disease is an entity of localized infection that involves tooth-supporting tissues. The first clinical manifestation of periodontal disease is the appearance of periodontal pockets, which offer a favorable niche for bacterial colonization. The etiology of periodontal disease is multifactorial, being caused by interactions between multiple micro-organisms (necessary but not sufficient primary etiologic factors), a host with some degree of susceptibility and environmental factors. According to current scientific evidence, there is a symbiotic relationship between diabetes and periodontitis, such that diabetes is associated with an increased incidence and progression of periodontitis, and periodontal infection is associated with poor glycaemic control in diabetes due to poor immune systems. Hence, for a good periodontal control it is necessary to treat both periodontal disease and glycaemic control.

Periodontal disease and diabetes mellitus

Periodontal disease (PD) is one of the most commonly known human chronic disorders. The relationship between PD and several systemic diseases such as diabetes mellitus (DM) has been increasingly recognized over the past decades.

OBJECTIVE

The purpose of this review is to provide the reader with knowledge concerning the relationship between PD and DM. Many articles have been published in the English and Portuguese literature over the last 50 years examining the relationship between these two chronic diseases. Data interpretation is often confounded by varying definitions of DM, PD and different clinical criteria were applied to determine the prevalence, extent and severity of PD, levels of glycemic control and diabetes-related complications.

METHODS

This paper provides a broad overview of the predominant findings from research conducted using the BBO (Bibliografia Brasileira de Odontologia), MEDLINE, LILACS and PubMed for Controlled Trials databases, in English and Portuguese languages published from 1960 to October 2012. Primary research reports on investigations of relationships between DM/DM control, PD/periodontal treatment and PD/DM/diabetes-related complications identified relevant papers and meta-analyses published in this period.

RESULTS

This paper describes the relationship between PD and DM and answers the following questions: 1- The effect of DM on PD, 2- The effects of glycemic control on PD and 3- The effects of PD on glycemic control and on diabetes-related complications.

CONCLUSIONS

The scientific evidence reviewed supports diabetes having an adverse effect on periodontal health and PD having an adverse effect on glycemic control and on diabetes-related complications. Further research is needed to clarify these relationships and larger, prospective, controlled trials with ethnically diverse populations are warranted to establish that treating PD can positively influence glycemic control and possibly reduce the burden of diabetes-related complications.

Minor manifestations of periodontal diseases in young adults with type 1 diabetes mellitus. Periodontal and microbiological findings

OBJECTIVE

The aim of this study was to evaluate periodontal status and microbiological conditions in young adults with insulin-dependent diabetes (IDDM) in comparison with age- and sex-matched non-diabetic controls.

MATERIALS AND METHODS

Forty-one patients, 18-24 years of age with IDDM since childhood, were examined and the results were compared to those of a group of 41 sex- and age-matched non-diabetic controls. According to the HbA(1c) %, the group of diabetic patients was divided into two groups, with good or poor metabolic control.

RESULTS

Periodontal health, expressed in probing pocket depths and marginal bone loss, was fairly good in all patients. Fifty per cent of the patients in the study and control groups displayed probing pocket depths ≥4 mm, mostly pocket depths 4 mm. These findings were also equally distributed among the patients with good and poor metabolic control. No significant differences were found between the groups regarding bleeding on probing, but in the number of sites with excessive bleeding the study group exhibited higher scores than the healthy controls. Different microbiological species were equally distributed between the groups.

CONCLUSION

Neither periodontal nor microbiological status in young adults with IDDM differs from that of healthy controls.

Reduction in HbA1c levels following non-surgical periodontal therapy in type-2 diabetic patients with chronic generalized periodontitis: A periodontist's role

Background:

Aim of the study was to compare the response to non-surgical periodontal therapy between patients with and without type-2 diabetes from clinical and metabolic stand point.

Materials and Methods:

A comparative clinical study was performed between type 2 diabetics and non-diabetics with moderate generalized chronic periodontitis. The study period was six months. Conventional periodontal scaling and root planing were performed, and the response to this treatment was compared between the groups at three and six months, measuring the plaque index, bleeding index, gingival index, and probing depth. In diabetic patients, the clinical response was related to measurements of HbA1c and glucose in blood at three and six months.

Statistical Analysis:

Multi Variant Analysis of Variance was used to compare following variables between groups and function of time.

Results:

Improvement in all clinical variables was observed in both the groups. The improvement observed in blood HbA1c levels in diabetic group confirmed a positive metabolic response to non-surgical periodontal treatment.

Conclusion:

With this study, we conclude that there is a definite reduction in HbA1c level in diabetic patients after conventional non-surgical periodontal treatment.

The influence of type 1 and type 2 diabetes on periodontal disease progression: prospective results from the Study of Health in Pomerania (SHIP)

OBJECTIVE

To explore associations between diabetes etiology (type 1 diabetes mellitus [T1DM] vs. T2DM) and glycemic control in the prediction of 5-year periodontal status change.

RESEARCH DESIGN AND METHODS

The Study of Health in Pomerania (SHIP) is a population-based stratified sample of German men and women. Healthy participants and those determined to have T2DM arose from the SHIP cohort, and T1DM participants were recruited from diabetes clinics in the catchment area that gave rise to SHIP. Dentate participants (n = 2,626; 53% women; 20-81 years of age) were included. Diabetes was determined via physician diagnosis and/or HbA(1c) ≥6.5% (uncontrolled diabetes >7.0%). Examiners blinded to diabetes status performed random half-mouth periodontal examinations, assessing probing depth (PD) and attachment loss (AL) (four sites/tooth) at baseline and follow-up. Participants were categorized into six groups as follows: 1) diabetes free (n = 2,280), 2) incident T2DM (n = 79), 3) controlled T2DM (n = 80), 4) uncontrolled T2DM (n = 72), 5) controlled T1DM (n = 43), and 6) uncontrolled T1DM (n = 72). In multivariable regressions, mean PD change (ΔMPD), mean AL change (ΔMAL), or incident tooth-loss values were regressed across the aforementioned diabetes categories.

RESULTS

Mean (SD) ΔMPD and ΔMAL values among all participants were -0.08 ± 0.5 mm and 0.08 ± 1.03 mm, respectively, and 34% lost one or more teeth. Relative to diabetes-free participants, those with uncontrolled T2DM experienced greater ΔMPD ± SE (P < 0.05), whereas participants with either uncontrolled T1DM or uncontrolled T2DM realized greater ΔMAL (P < 0.05). Uncontrolled T1DM and T2DM were both associated with an increased risk of future tooth loss (P < 0.05).

CONCLUSIONS

Diabetes control, but not etiology, was associated with future tooth loss and accelerated AL progression.

Patterns of Dental Diseases in Diabetic Females in Primary Health Centers in Qatar: Cross-sectional, observational study

Periodontal diseases comprise a large group of predominantly infectious and/or inflammatory disorders affecting periodontal tissues. They are diagnosed by assessment of the dento-gingival area, including the the gingival sulcus depth, and the presence of bleeding with radiographic assessment of the alveolar bone. The prevalence of periodontitis (PD) is reported to be 20-50% worldwide;(1) while the aggressive form of PD is found in less than 10% of the population/2,3). Periodontitis is a chronic infectious/inflammatory disease of multi-factorial etiology(4) with a number of risk factors that are shared with other chronic inflammatory conditions; increasing age, low socio-economic conditions, stress, increased body weight, dyslipidemia, hypertension, metabolic syndrome, cigarette smoking and Diabetes mellitus.(5-6) Systemic reviews have shown a clear association between PD and coronary heart diseases (CHD) emphasizing the need to consider PD as a risk factor for CHD.

Evaluation of periodontal status and effectiveness of non-surgical treatment in patients with type 2 diabetes mellitus in Taiwan for a 1-year period

BACKGROUND

The periodontal status and effects of non-surgical periodontal treatment in patients with type 2 diabetes mellitus and periodontal disease are assessed.

METHODS

One-hundred patients with type 2 diabetes (mean ± SD hemoglobin (Hb)A1c level: 7.3% ± 0.94%) and periodontal disease were recruited for this study. The group with moderate-to-severe periodontal disease included patients with >1 tooth with a probing depth (PD) ≥5 mm and >2 teeth with a clinical attachment loss (AL) ≥ 6mm, and the group with mild periodontal disease included patients with <1 affected tooth, and >2 affected with a clinical AL ≥ 6mm. Patients (28 patients in the mild group and 72 patients in the moderate-to-severe group) underwent non-surgical periodontal treatments. We analyzed differences in serum concentrations of metabolic parameters (glycated hemoglobin and low-density lipoprotein), inflammatory parameters (interleukin [IL]-1β and C-reactive protein [CRP]), and periodontal parameters between the two groups before treatment and at 3, 6, 9, and 12 months post-therapy.

RESULTS

Seventy-five patients with diabetes (21 patients in the mild group and 54 patients in the moderate-to-severe group) completed the study. Significant differences in the plaque index (PI), gingival index (GI), PD, and clinical AL at examination times were observed in the whole cohort (P <0.05). We observed significant differences in the PI, GI, and PD in the moderate-to-severe group (P <0.05), whereas there was only a significant difference in PD in the mild group (P <0.05) between baseline and 12 months post-treatment. Both groups experienced improved glycemic control, but the difference was insignificant. CRP and IL-1β levels were significantly different at examination times for the whole cohort (P <0.05). No significant positive association among metabolic and inflammatory parameters at 12 months post-therapy were found.

CONCLUSION

Non-surgical periodontal treatment improved and maintained the periodontal health of patients with well-controlled diabetes, but no significant reduction of metabolic parameters was observed over a 1-year period.

Diabetes, periodontitis, and the subgingival microbiota

Both type 1 and type 2 diabetes have been associated with increased severity of periodontal disease for many years. More recently, the impact of periodontal disease on glycaemic control has been investigated. The role of the oral microbiota in this two-way relationship is at this stage unknown. Further studies, of a longitudinal nature and investigating a wider array of bacterial species, are required in order to conclusively determine if there is a difference in the oral microbiota of diabetics and non-diabetics and whether this difference accounts, on the one hand, for the increased severity of periodontal disease and on the other for the poorer glycaemic control seen in diabetics.

Cytokine levels in sites of chronic periodontitis of poorly controlled and well-controlled type 2 diabetic subjects

AIM

This study compared the levels of tumour necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-4, IL-17 and IL-23 in the gingival crevicular fluid (GCF) from well-controlled and poorly controlled type 2 diabetic subjects with chronic periodontitis, before and after periodontal therapy.

MATERIAL AND METHODS

Eighteen well-controlled (glycated haemoglobin levels ≤8%) and 20 poorly controlled (glycated haemoglobin levels >8%) diabetic subjects were enrolled in this study. All subjects were submitted to non-surgical periodontal therapy. GCF sampling and clinical periodontal parameters were assessed before, 3 and 6 months post-therapy. Total amounts and concentrations of TNF-α, IFN-γ, IL-4, IL-17 and IL-23 in the GCF were analysed by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The levels of IL-17 were higher in poorly than in well-controlled subjects (p<0.05), whereas the levels of IFN-γ were increased in well- compared with poorly controlled subjects at all experimental groups (p<0.05). In addition, IL-4 levels were lower in well- than poorly controlled diabetic subjects at baseline (p<0.05). There were no differences between groups for TNF-α and IL-23 at any time points (p>0.05).

CONCLUSION

These results indicate a predominance of pro-inflammatory T-helper type 1 (Th1)- or Th17-cytokines in sites of chronic periodontitis from type 2 diabetic subjects, according to their glycaemic control.

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.

Characteristics of inflammation common to both diabetes and periodontitis: are predictive diagnosis and targeted preventive measures possible?

Diabetes and periodontitis are chronic inflammatory disorders that contribute to each others' severity and worsen each others' prognosis. Studies have shown that patients with diabetes are at increased risk of developing periodontitis, and that diabetics with untreated periodontitis have more difficulty controlling serum glucose. Periodontal treatment that reduces gingival inflammation aids in the control of hyperglycemia. Periodontitis is accompanied by gingival bleeding and the production of an inflammatory exudate termed gingival crevicular fluid (GCF) that arises from the inflamed gingival tissues surrounding the teeth. GCF contains byproducts of connective tissue degradation, enzymes from host and bacterial cells, cytokines and other inflammatory mediators, and has been studied for screening blood glucose and for biomarkers of both diabetes and periodontitis. This review focuses on the inter-relationship between diabetes and periodontitis and the biomarkers common to both these diseases that may enable earlier detection, targeted preventive measures and individualized therapeutic intervention of these chronic conditions.

Effectiveness of full-mouth and partial-mouth scaling and root planing in treating chronic periodontitis in subjects with type 2 diabetes

BACKGROUND

This study evaluated the clinical and metabolic effects of full-mouth scaling and root planing (FMSRP) compared to partial-mouth scaling and root planing (PMSRP) in patients with type 2 diabetes and chronic periodontitis, and it assessed the impact of the glycemic status on the clinical and metabolic response to periodontal therapy.

METHODS

In this clinical trial, 18 subjects with diabetes received FMSRP in a maximum of 24 hours, and 18 subjects received PMSRP in a maximum of 21 days. Visible plaque accumulation, bleeding on probing, suppuration, probing depth, clinical attachment level (CAL), and glycosylated hemoglobin (HbA1c) levels were obtained at baseline and at 3 and 6 months post-therapy. Baseline HbA1c values > or =9% and <9% defined subjects with poorly and better-controlled diabetes, respectively.

RESULTS

All clinical parameters improved after therapy (P <0.05). No significant differences were observed between treatment groups for clinical and metabolic parameters at any time (P >0.05). There were no changes in the HbA1c levels after therapy (P >0.05). No subject reported any adverse effects during the study. Individuals with better-controlled diabetes achieved a lower mean CAL at 6 months post-therapy, when FMSRP and PMSRP were evaluated together (P <0.05).

CONCLUSIONS

FMSRP and PMSRP were equally effective in treating chronic periodontitis in subjects with type 2 diabetes, without significant improvements in the glycemic control at 3 and 6 months. Considering the periodontal therapy as a whole (FMSRP plus PMSRP), subjects with better-controlled diabetes exhibited a benefit in CAL at 6 months compared to subjects with poorly controlled disease.

Effect of diabetes on periodontal status of a population with poor oral health

OBJECTIVE

Diabetes is a global health problem and its prevalence is increasing worldwide. The objective of the study was to investigate the effect of diabetes on the periodontal status of a Pakistani population with poor oral hygiene.

MATERIAL AND METHODS

Eighty-eight individuals with diabetes and 80 non-diabetic individuals were recruited from a disadvantaged district in Karachi, Pakistan. The group with diabetes comprised 50 males and 38 females, and the non-diabetic group 43 males and 37 females. All underwent clinical and radiographic examination.

RESULTS

The average numbers of teeth in the diabetes and non-diabetes groups were 24 and 26, respectively. The odds ratio (OR) for missing or fewer teeth was 2.3 times higher for diabetics than for non-diabetics (CI 1.32-4.14; p<0.001). Diabetic patients had more sites with plaque than did non-diabetics (OR 1.96, CI 0.99-3.88; p<0.056). Moderate to severe periodontitis was significantly more prevalent among diabetic patients (p<0.01).

CONCLUSION

In this disadvantaged population with poor oral hygiene, diabetes has had a strongly negative influence on oral health: diabetic patients have fewer teeth, more plaque, and a higher prevalence of moderate to severe periodontal disease than non-diabetics.

Radiolucency below the crown of mandibular horizontal incompletely impacted third molars and acute inflammation in men with diabetes

Although mandibular third molar has a high risk of infection extending any complications, the influence of diabetes on radiolucency and acute inflammation in pericoronitis remains unclear. The present study was to evaluate whether radiolucency below the crown is related to acute inflammation in mandibular horizontal incompletely impacted third molars and to review the records of 140 men more than 45 years with and without diabetes. The odds ratio of exhibiting acute inflammation was 3.38 (95% CI: 1.13-10.16, p < 0.05) and that of exhibiting severe acute inflammation was 15.38 (95% CI: 3.56-66.49, p < 0.0001), indicating an association of acute pericoronitis in diabetes. The frequency of radiolucency below the crown and below the root in diabetics was similar to that in nondiabetics. However, the odds ratio of exhibiting both radiolucency below the crown and acute inflammation under the diabetic condition was 4.85 (95% CI: 1.60-14.73, p < 0.01), whereas that of diabetics showing both radiolucency below the root and acute inflammation was 0.46 (95% CI: 0.06-3.74, p = 0.74). Radiolucency below the crown and acute inflammation were associated with diabetes, but that below root and acute inflammation were not associated with diabetes, indicating that the region below the crown carries susceptibility to acute pericoronitis, whereas the periodontium shows a protective effect against acute pericoronitis.

Efficacy of periodontal treatment on glycaemic control in diabetic patients: A meta-analysis of interventional studies

AIM

There is growing evidence that periodontal disease may favour the incidence or aggravation of diabetes and its complications. To investigate the issue, we conducted a meta-analysis of the effect of periodontal therapy on glycaemic control in diabetic patients.

METHODS

A literature search was carried out using seven databases (Medline, EMBASE, LILACS, The Cochrane Library, Pascal, IADR Abstracts and Current Contents), with no language restrictions. We followed the QUOROM-recommended standards for improving the quality of reporting meta-analyses of interventional studies.

RESULTS

Twenty-five studies, involving 976 subjects altogether, were included in the present systematic review. Of these, nine studies, involving a total of 485 patients, were controlled trials and were included in the meta-analysis. The standardized mean difference in HbA(1c) with the treatment of periodontal disease was 0.46 (95% CI: 0.11, 0.82). These findings suggest that periodontal treatment could lead to a significant 0.79% (95% CI: 0.19, 1.40) reduction in HbA(1c) level.

CONCLUSION

The present meta-analysis represents the best information available to date that addresses this issue, and suggests that periodontal treatment could improve glycaemic control. Nevertheless, these results need to be viewed with caution because of a lack of robustness, and deficiencies in the design of some of the studies included. A randomized controlled trial with sufficient statistical power would help to confirm the results of this meta-analysis.

Periodontal disease: associations with diabetes, glycemic control and complications

OBJECTIVE

This report reviews the evidence for adverse effects of diabetes on periodontal health and periodontal disease on glycemic control and complications of diabetes.

DESIGN

MEDLINE search of the English language literature identified primary research reports published on (a) relationships between diabetes and periodontal diseases since 2000 and (b) effects of periodontal infection on glycemic control and diabetes complications since 1960.

RESULTS

Observational studies provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal disease in 13/17 reports reviewed. Treatment and longitudinal observational studies provided evidence to support periodontal infection having an adverse effect on glycemic control, although not all investigations reported an improvement in glycemic control after periodontal treatment. Additionally, evidence from three observational studies supported periodontal disease increasing the risk for diabetes complications and no published reports refuted the findings.

CONCLUSION

The evidence reviewed supports diabetes having an adverse effect on periodontal health and periodontal infection having an adverse effect on glycemic control and incidence of diabetes complications. Further rigorous study is necessary to establish unequivocally that treating periodontal infections can contribute to glycemic control management and to the reduction of the burden of diabetes complications.

Gingival crevicular fluid PGE2, IL-1beta, t-PA, PAI-2 levels in type 2 diabetes and relationship with periodontal disease

OBJECTIVES

To evaluate if type 2 diabetes mellitus increase gingival crevicular fluid (GCF) levels of prostaglandin E(2) (PGE(2)), interleukin-1beta (IL-1beta), tissue-type plasminogen activator (t-PA), and plasminogen activator inhibitor-2 (PAI-2).

DESIGN AND METHODS

Seventeen type 2 diabetic patients with periodontal disease (DM), 17 otherwise healthy periodontally diseased patients (PD) and 17 systemically and periodontally healthy control subjects (H) were enrolled. Clinical periodontal measurements were recorded at six sites/tooth. GCF samples were analyzed by ELISA. Data were tested by statistical tests.

RESULTS

DM group revealed lower IL-1beta levels than PD group (p<0.01). PGE(2), t-PA and PAI-2 levels were similar in DM and PD groups (p>0.05). PGE(2), t-PA levels were higher in DM and PD groups than H group (p<0.05). PAI-2 level was higher in DM group than H group (p<0.05). GCF total amount of PGE(2) in DM group exhibited significant correlations with all clinical periodontal measurements (p<0.05).

CONCLUSION

Type 2 diabetes in this study seems not to increase GCF levels of the evaluated inflammatory mediators.

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.

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.

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.

Periodontal disease and diabetes

BACKGROUND

The association between diabetes and inflammatory periodontal diseases has been studied extensively for more than 50 years. The author reviews the bidirectional relationships between diabetes and periodontal diseases.

CONCLUSIONS

A large evidence base suggests that diabetes is associated with an increased prevalence, extent and severity of gingivitis and periodontitis. Furthermore, numerous mechanisms have been elucidated to explain the impact of diabetes on the periodontium. While inflammation plays an obvious role in periodontal diseases, evidence in the medical literature also supports the role of inflammation as a major component in the pathogenesis of diabetes and diabetic complications. Research suggests that, as an infectious process with a prominent inflammatory component, periodontal disease can adversely affect the metabolic control of diabetes. Conversely, treatment of periodontal disease and reduction of oral inflammation may have a positive effect on the diabetic condition, although evidence for this remains somewhat equivocal.

CLINICAL IMPLICATIONS

Patients with diabetes who have periodontal disease have two chronic conditions, each of which may affect the other, and both of which require frequent professional evaluations, in-depth patient education and consistent educational reinforcement by health care providers.

Diabetes mellitus and periodontal diseases

BACKGROUND

The purpose of this review is to provide the reader with practical knowledge concerning the relationship between diabetes mellitus and periodontal diseases. Over 200 articles have been published in the English literature over the past 50 years examining the relationship between these two chronic diseases. Data interpretation is often confounded by varying definitions of diabetes and periodontitis and different clinical criteria applied to prevalence, extent, and severity of periodontal diseases, levels of glycemic control, and complications associated with diabetes.

METHODS

This article provides a broad overview of the predominant findings from research published in English over the past 20 years, with reference to certain "classic" articles published prior to that time.

RESULTS

This article describes current diagnostic and classification criteria for diabetes and answers the following questions: 1) Does diabetes affect the risk of periodontitis, and does the level of metabolic control of diabetes have an impact on this relationship? 2) Do periodontal diseases affect the pathophysiology of diabetes mellitus or the metabolic control of diabetes? 3) What are the mechanisms by which these two diseases interrelate? and 4) How do people with diabetes and periodontal disease respond to periodontal treatment?

CONCLUSIONS

Diabetes increases the risk of periodontal diseases, and biologically plausible mechanisms have been demonstrated in abundance. Less clear is the impact of periodontal diseases on glycemic control of diabetes and the mechanisms through which this occurs. Inflammatory periodontal diseases may increase insulin resistance in a way similar to obesity, thereby aggravating glycemic control. Further research is needed to clarify this aspect of the relationship between periodontal diseases and diabetes.

Clinical and metabolic changes after conventional treatment of type 2 diabetic patients with chronic periodontitis

BACKGROUND

The aim of this study was to compare the response to conventional periodontal treatment between patients with or without type 2 diabetes mellitus from a clinical and metabolic standpoint.

METHODS

A prospective, parallel, comparative longitudinal clinical study was performed between type 2 diabetics and non-diabetics with moderate generalized chronic periodontitis. The study period was 6 months. Conventional periodontal scaling and root planing were performed, and the response to this treatment was compared between the groups at 3 and 6 months, measuring the plaque index, bleeding on probing, probing depth, level of clinical attachment, and gingival recession. In the diabetic patients, the clinical response was related to measurements of HbA1c and glucose in blood at 3 and 6 months.

RESULTS

An improvement in all clinical variables was observed, with no statistically significant differences between the groups, with the exception of probing depth (P <0.0207). The improvement observed in blood HbA1c levels confirmed a positive metabolic response to periodontal treatment, with a lower value for this variable at each measurement time.

CONCLUSIONS

Both groups of patients showed a clinical improvement after basic non-surgical periodontal treatment. The diabetic patients showed improved metabolic control (lower HbA1c) at 3 and 6 months after periodontal treatment.

Periodontitis deteriorates metabolic control in type 2 diabetic Goto-Kakizaki rats

BACKGROUND

Epidemiologic and clinical studies have indicated that periodontal disease (PD) may cause disturbances in general health and even affect diabetes. The aim of this study was to gain knowledge on the effect of PD on diabetes metabolic control in a new model for type 2 diabetes-associated PD (i.e., the Goto-Kakizaki [GK] rat).

METHODS

GK rats represented the type 2 diabetes group and were allocated into two groups: diabetes or diabetes+PD group; Wistar rats represented the non-diabetes group and were divided into non-diabetes+PD and non-diabetes groups. PD was induced by placing ligatures around second maxillary molars, and the animals were followed for 6 weeks. Serum insulin, glucose, and free fatty acid levels were evaluated; interleukin (IL)-1beta, IL-6, and tumor necrosis factor-alpha were measured in adipose tissue supernatant; glucose tolerance and insulin resistance were calculated. Further, alveolar bone destruction was estimated morphometrically and radiographically.

RESULTS

Rats with diabetes+PD became almost 30% more glucose intolerant (P<0.01) and presented a 25% increase in IL-1beta in adipose tissue (P<0.05) compared to rats from the diabetes group. Moreover, PD associated with diabetes resulted in more alveolar bone destruction in comparison to PD in the absence of diabetes (P<0.01).

CONCLUSIONS

Our results indicated that PD deteriorates metabolic control in diabetes, which emphasizes that PD may play a significant role for the course of diabetes. The GK rat can represent a suitable model for further studies on the association between PD and 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.

Diabetes and its effects on dental pulp

Uncontrolled or poorly controlled diabetes mellitus may be a risk factor for the development of oral complications. The objective of this investigation was to determine the effect of diabetes mellitus progression on inflammatory and structural components of dental pulp. Male Wistar rats were given a single injection of Streptozotocin (STZ), and induction of diabetes was confirmed 24 h later. Dental pulp tissue samples were taken from central incisors and molars of diabetic rats 30 and 90 days after the STZ treatment. Plasma glucose levels in diabetic rats 30 and 90 days after STZ treatment were significantly increased when compared to control rats (P < 0.001). Nitrite and kallikrein levels in dental pulp tissue were higher in diabetic rats 30 days after STZ treatment than in controls, while only nitrite were decreased 90 after of STZ treatment. Myeloperoxidase activity showed changes 30 and 90 days after STZ injection when compared to controls. The activity of alkaline phosphatase showed significant changes 30 and 90 days after STZ treatment. On the other hand the concentration of collagen was decreased in diabetic rats 30 and 90 days after STZ injection. These results suggest that diabetes is a critical factor that has profound effects upon oral tissues, resulting in expression of inflammatory mediators and modifications of structural components of dental pulp.

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.

Experimental gingivitis in type 1 diabetics: a controlled clinical and microbiological study

OBJECTIVE

To monitor clinical and microbiological changes during experimental gingivitis in type 1 diabetics and non-diabetics.

MATERIALS AND METHODS

Nine type 1 diabetics with good/moderate metabolic control and nine age-gender matched non-diabetics were recruited. Probing pocket depths in all subjects did not exceed 4 mm and none were affected by attachment loss. According to the original model, an experimental 3-week plaque accumulation resulting in experimental gingivitis development and a subsequent 2-week period of optimal plaque control were staged. Subgingival plaque samples were collected at days 0, 21 and 35 from one site per quadrant, pooled and analysed using checkerboard DNA-DNA hybridization.

RESULTS

Diabetics (mean age 25.6+/-5.8 standard deviation (SD), range 16-35 years) had a mean HbA1c level of 8.1+/-0.7% (SD), while non-diabetics (mean age 24.8+/-5.7 (SD), range 15-36 years) were metabolically controlled (HbA1c< or =6.5%). Between Days 0, 21 and 35, no statistically significant differences in mean plaque and gingival index scores were observed between diabetics and non-diabetics. At days 7 and 21, however, diabetics showed statistically significantly higher percentages of sites with gingival index scores > or =2 compared with non-diabetics. Mean DNA probe counts of the red and orange complex species increased significantly (p<0.05) between days 0 and 21 and decreased significantly (p<0.05) between days 21 and 35 in both groups.

CONCLUSION

Both diabetics and non-diabetics react to experimental plaque accumulation with gingival inflammation. Type 1 diabetics, however, develop an earlier and higher inflammatory response to a comparable bacterial challenge.