Periodontal disease and type I diabetes mellitus in children and adolescents

Periodontal risk markers in children and adolescents with type 1 diabetes: A systematic review and meta-analysis

BACKGROUND

Periodontal disease is a frequent complication of diabetes in adults, and both conditions are associated with systemic inflammatory states. This systematic review and meta-analysis was conducted to establish the relative severity of periodontal disease risk markers in children and adolescents with type 1 diabetes (T1D).

METHODS

A systematic search strategy using PubMed and EMBASE databases was performed to identify relevant studies assessing periodontal risk markers in children and adolescents and T1D through to February 2019. Eligible studies were assessed for quality and heterogeneity, and a random effects model was used to estimate differences in selected periodontal risk markers in children with T1D relative to healthy controls.

RESULTS

The search identified 551 studies from which 23 were found to meet the inclusion criteria. Random effects meta-analyses demonstrated that relative to healthy controls, children and adolescents with T1D had higher mean values for plaque index, gingival index, bleeding on probing, pocket depth and clinical attachment loss (all P < .001).

CONCLUSIONS

Risk markers for periodontal disease were found to be more pronounced among children and adolescents with T1D compared to healthy controls. Early referral of these at risk individuals for dental examination is recommended to allow for early intervention.

Type 1 diabetes and periodontitis: prevalence and periodontal destruction-a systematic review

AIMS

Data about the association between periodontal disease or periodontitis (PD), diabetes and hyperglycemia have been reported mostly in patients with type 2 diabetes. Conversely, information about PD in type 1 diabetes (T1DM) is relatively scarce. The aim of this meta-analysis is therefore: (1) to assess the prevalence and severity of PD in patients affected by T1DM in comparison with the general population and (2) to verify the association between severity of PD and glycemic control in type 1 diabetics.

METHODS

An electronic search was performed on MEDLINE, Cochrane Central Register of Trials and EMBASE, up to October 31, 2019. Estimates of prevalence of PD in T1DM were calculated together with Mantel-Haenszel odds ratios (MH-OR) of the risk of PD associated with T1DM; weighed mean difference in CAL between T1DM and control and weighed mean difference in CAL in patients with T1DM and unsatisfactory glycemic control as compared with those in good glycemic control were also evaluated..

RESULTS

The prevalence of PD in type 1 diabetes was 18.5 [8.0; 37.1] %; the MH-OR for PD is 2.51 (1.32;4.76) in T1DM patients versus general population (p = 0.005). The weighed mean difference in CAL depth between T1DM patients and controls is 0.506 [0.181; 0.832] mm (p < 0.005), and in T1DM patients with good glycemic control CAL depth is - 0.71 [- 1.00; - 0.42] mm less deep than in subjects with HbA1c > 7%.

CONCLUSIONS

The present data confirm that T1DM is a relevant risk factor for the development of PD. The proportion of patients affected by PD is more than doubled in subjects with T1DM in comparison with non-diabetic individual, and among patients with T1DM, PD seems to be more severe and the differences appear very wide between subjects in optimal and suboptimal glycemic control.

Clinical and microbial oral health status in children and adolescents with type 1 diabetes mellitus

OBJECTIVES

To study the oral health of young individuals with controlled and uncontrolled type 1 diabetes mellitus (T1DM) and compare the results with those for healthy counterparts.

MATERIALS AND METHODS

One-hundred and forty-four youngsters (6-15 years of age) were assigned, according to glycaemic control, to three study groups: (i) diabetic patients with poor glycaemic control [glycated haemoglobin (HbA1c ≥7.5%)] (n = 35); (ii) diabetic patients with good glycaemic control (HbA1c <7.5%) (n = 39); and (iii) healthy individuals (n = 70). Plaque, gingival inflammation, calculus and decayed, missing and filled surfaces (DMFS) indices were recorded. Salivary parameters were determined, and stimulated saliva was collected to allow detection and determination of the levels of oral Candida albicans and Streptococcus mutans by real-time polymerase chain reaction (PCR).

RESULTS

Significantly different amounts of plaque were found among the study groups (P = 0.024): youngsters with poor glycaemic control had significantly more plaque than youngsters in the other two groups. The gingival, calculus and DMFS indices were not significantly different among groups (P > 0.05). Candida albicans levels were not statistically significant different among groups, but the group with poor glycemic control showed an elevated frequency of detection. Streptococcus mutans was isolated from the oral cavity of 96 of the 144 individuals. A statistically significant difference in the level of S. mutans was found between the group with poor glycaemic control and the healthy control group (P = 0.032).

CONCLUSIONS

The results imply that youngsters with T1DM have a lower level of oral hygiene and are potentially at a higher risk of future oral disease, particularly when their metabolic disorder is uncontrolled. However, factors outside the oral cavity may also have a considerable impact on the initiation and progression of oral diseases.

Influence of Periodontal Disease on cardiovascular markers in Diabetes Mellitus patients

The objective of the present study was to establish if individuals with Diabetes Mellitus (DM2) and periodontal diseases (gingivitis or periodontitis) presented an increase in the concentration of modified LDL (moLDL) and what is the influence of periodontal treatment on the decrease of moLDL particles with consequent improvement in the parameters of DM2. Twenty-four diabetic patients with periodontitis (Group 1) and twenty-four diabetic patients with gingivitis (Group 2) were followed up for a period of 12 months. Group 1 was treated with periodontal debridement, and Group 2 received supra-gingival scaling and prophylaxis. In both groups, periodontal clinical parameters: probing depth (PD), clinical attachment level (CAL), gingival resection (GR), bleeding on probing index (BOP) and plaque index; inflammatory serum markers (glycemia, A1c, total cholesterol, HDL-cholesterol (HDL-c), LDL-cholesterol (LDL-c), triglycerides and hs-CRP) and oxidized LDL (oxLDL) were measured at baseline, t = 6 and t = 12 months after treatment. Solutions of LDL were analyzed using the nonlinear optical Z-Scan and optical absorption techniques. The periodontal clinical parameters showed significant improvement (p < 0.05) in both Group after 12 months. For both groups, total cholesterol, HDL-c, LDL-c, triglycerides and A1c levels did not show significant reductions after periodontal therapy. hs-CRP levels in Group 1 presented a significant reduction after 12 months. The glycemic rate and the oxLDL concentrations did not show significant differences as a function of time. The optical measurements of LDL solutions revealed an improvement of the LDL-c quality in both groups. Periodontal debridement was able to improve periodontal parameters and the quality of LDL-c in diabetic patients but without changes in the oxLDL concentration in both groups. Considering the clinical relevance, the reduction of infectious and inflammatory sites present in the oral cavity through periodontal therapy may help with the control and prevention of hyperglycemia and precursors of cardiovascular diseases.

Frequency of putative periodontal pathogens among type 1 diabetes mellitus: a case-control study

Objective

The aim of the present study is to compare and assess the risk of periodontitis due to the presence of four putative periodontopathic bacteria viz., Eikenella corrodens, Campylobacter rectus, Prevotella intermedia and Prevotella nigrescens. To fulfil the above objective, polymerase Chain reaction using the primers targeting 16S rRNA gene of the bacterial species was performed with the subgingival plaque collected from the permanent first molars of type 1 diabetic children and age matched healthy children.

Results

The prevalence of periodontal pathogens in diabetic and healthy children was 6% and 16% for E. corrodens, 18% and 36% for C. rectus, 2% and 2% for P. intermedia, 4% and 0%, for P. nigrescens respectively. Statistically, significant difference was not observed for the prevalence of all the four periodontal pathogens between type 1 diabetic and healthy children (P = 1.00). The results of the present study thus reveal a negative correlation of type I diabetes to periodontitis in association to Eikenella corrodens, Campylobacter rectus, Prevotella intermedia and Prevotella nigrescens.

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.

Comparison of ultrasound imaging and cone-beam computed tomography for examination of the alveolar bone level: A systematic review

Background and objective

The current methods to image alveolar bone in humans include intraoral 2D radiography and cone-beam computed tomography (CBCT). However, these methods expose the subject to ionizing radiation. Therefore, ultrasound imaging has been investigated as an alternative technique, as it is both non-invasive and free from ionizing radiation. In order to assess the validity and reliability of ultrasonography in visualizing alveolar bone, a systematic review was conducted comparing ultrasound imaging to CBCT for examination of the alveolar bone level.

Study design

Seven databases were searched. Studies addressing examination of alveolar bone level via CBCT and ultrasound were selected. Risk of bias under Cochrane guidelines was used as a methodological quality assessment tool.

Results

All the four included studies were ex vivo studies that used porcine or human cadaver samples. The alveolar bone level was measured by the distance from the alveolar bone crest to certain landmarks such as cemento-enamel junction or gingival margin. The risk of bias was found as low. The mean difference between ultrasound and CBCT measurements ranged from 0.07 mm to 0.68 mm, equivalent to 1.6% - 8.8%.

Conclusions

There is currently preliminary evidence to support the use of ultrasonography as compared to CBCT for the examination of alveolar bone level. Further studies comparing ultrasound to gold standard methods would be necessary to help validate the accuracy of ultrasonography as a diagnostic technique in periodontal imaging.

Estimation of gingival crevicular blood glucose level for the screening of diabetes mellitus: A simple yet reliable method

AIM

This study was designed to assess the reliability of blood glucose level estimation in gingival crevicular blood(GCB) for screening diabetes mellitus.

MATERIALS AND METHOD

70 patients were included in study. A randomized, double-blind clinical trial was performed. Among these, 39 patients were diabetic (including 4 patients who were diagnosed during the study) and rest 31 patients were non-diabetic. GCB obtained during routine periodontal examination was analyzed by glucometer to know blood glucose level. The same patient underwent for finger stick blood (FSB) glucose level estimation with glucometer and venous blood (VB) glucose level with standardized laboratory method as per American Diabetes Association Guidelines.¹ All the three blood glucose levels were compared. Periodontal parameters were also recorded including gingival index (GI) and probing pocket depth (PPD).

RESULTS

A strong positive correlation (r) was observed between glucose levels of GCB with FSB and VB with the values of 0.986 and 0.972 in diabetic group and 0.820 and 0.721 in non-diabetic group. As well, the mean values of GI and PPD were more in diabetic group than non-diabetic group with the statistically significant difference (p < 0.005).

CONCLUSION

GCB can be reliably used to measure the blood glucose level as the values were closest to glucose levels estimated by VB. The technique is safe, easy to perform and non-invasive to the patient and can increase the frequency of diagnosing diabetes during routine periodontal therapy.

Oral health of children with type 1 diabetes mellitus: A systematic review

AIM

This systematic review investigated the oral health status of children with type 1 diabetes.

METHODS

A systematic search was conducted using PubMed/Medline, Web of Knowledge, SCOPUS and EMBASE. The search included all studies published from inception of database to January 2014. A total of 1179 abstracts were analyzed for selection in 2 phases. The first phase selection was based on the title and abstracts alone. The selected abstracts were then included for second phase, where full articles were obtained. The selection was carried out by 2 independent reviewers (Kappa value=0.809). Only 37 articles were included for final analysis in this review.

RESULTS

There is conflicting evidence in the caries experience between children with type 1 diabetes and healthy children. For periodontal health, most studies reported significantly greater plaque accumulation and higher gingival index in children with type 1 diabetes. Cohort studies reported no significant differences in perioodontal parameters over time.

CONCLUSIONS

There is conflicting evidence regarding the caries experience of children with type 1 diabetes, but they exhibit poorer periodontal health status with greater plaque accumulation compared to healthy children. Further studies are warranted to assess the oral health status of children with type 1 diabetes.

Candida spp. and gingivitis in children with nephrotic syndrome or type 1 diabetes

Background

Diabetes and Nephrotic syndrome (NS) promote plaque-related gingivitis and yeast-like fungal infections.

The study assesses the impact of Candida spp. and general disease- or treatment-related factors on plaque-related gingivitis severity in children and adolescents with Nephrotic syndrome /diabetes.

Methods

Body mass index (BMI), BMI standard deviation score, and oral cavity (Plaque Index – PLI, Gingival Index – GI, mucosa status, presence and Candida enzymatic activity) were assessed in 96 patients (32 with NS: 30- immunosuppressive treatment, 35 - type 1 diabetes, and 29 generally healthy), aged; 3–18 years. Laboratory included cholesterol and triglyceride measurements; in diabetic subjects– glycated haemoglobin, in NS: total protein, albumin, creatinine, haemoglobin, haematocrit, white cell count, urinary protein excretion. Medical records supplied information on disease duration and treatment. A statistical analysis was performed; Kendall Tau coefficient, chi-square test, t-test, and multiple regression analysis ( P < 0.05).

Results

Candida spp. often occurred in healthy patients, but oral candidiasis was found only in the NS and diabetes groups (9.37% and 11.43%). Gingivitis occurred more frequently in patients with NS/diabetes. Gingivitis severity was correlated with PLI, age, and yeast enzyme activity in NS – to with immunosuppressive treatment with >1 drug, drug doses, treatment duration, lipid disorders, and BMI; in diabetes, with blood glucose and glycated haemoglobin >8%.

Conclusion

Poor hygiene control is the main cause of gingivitis. Gingivitis severity is most likely related to age, lipid disorders and increase in body mass. Candida spp., in uncompensated diabetes and in those using immunosuppressive treatment, might intensify plaque-related gingivitis.

Periodontal health of children with type 1 diabetes mellitus in Kuwait: a case-control study

OBJECTIVE

The aim of this study was to evaluate periodontal health in children diagnosed with type 1 diabetes mellitus.

SUBJECTS AND METHODS

Periodontal health was clinically examined and compared in 95 children diagnosed with type 1 diabetes and 61 healthy control subjects (4-14 years old). Plaque index, gingival index, clinical attachment loss and bleeding on probing were assessed on the 6 Ramfjord index teeth. Diabetes history was recorded based on information provided by the physician from the medical record of each diabetic child. Diabetes history included date of diagnosis, diabetes duration, age at diagnosis, latest reading for glycosylated hemoglobin and any existing diabetes complications. Data were analyzed using the Statistical Package for Social Science software, version 18. 'Periodontitis' was defined as at least one site with clinical attachment loss >2 mm on at least 2 teeth.

RESULTS

Sixty-two of the diabetic children (65%) had poor compliance with dental care, and 42 of them (44%) had never visited the dentist before. The children with type 1 diabetes mellitus had a significantly higher plaque index and gingival index and more bleeding on probing than control subjects (p < 0.001). In the diabetic group, periodontitis was significantly associated with longer duration of diabetes (odds ratio 2.230, confidence interval 1.308-3.801; p = 0.003) and older age at diagnosis of diabetes (odds ratio 1.838, confidence interval 1.091-3.096; p = 0.022).

CONCLUSIONS

Periodontal disease in young patients with type 1 diabetes was more evident than in those without diabetes. These data showed that diabetes duration may play a significant role in the progression of periodontal disease in diabetic children.

Increased prevalence of cardiovascular and autoimmune diseases in periodontitis patients: a cross-sectional study

BACKGROUND

Associations between periodontitis and cardiovascular and autoimmune diseases are most often assessed in patients with a particular cardiovascular or autoimmune disease. To prevent selection bias, this study assesses the existence of associations between periodontitis and cardiovascular and autoimmune diseases in patients attending a dental or periodontal clinic.

METHODS

Data were collected from 1,276 randomly selected dental records from patients attending a dental (n = 588) or periodontal (n = 688) clinic. Data on the prevalence of cardiovascular and autoimmune diseases were obtained from a validated health questionnaire. Data on the presence of periodontitis were taken from patients' dental records.

RESULTS

In uncontrolled analyses, the prevalence of hypertension, diabetes mellitus (DM), and rheumatoid arthritis (RA) is significantly increased in patients with periodontitis. Controlled for confounding, periodontitis was associated with DM, with an odds ratio of 4 (1.03 to 15.3), in the dental clinic. DM was not associated with periodontitis in periodontal clinics. Hypertension does not seem to be associated with periodontitis when controlling for confounders. Periodontitis may be associated with RA in both clinic types.

CONCLUSIONS

The increased prevalence of cardiovascular and autoimmune diseases among patients with periodontitis attending dental or periodontal clinics may, at least in part, be influenced by confounding. However, the increased prevalence of DM and RA in patients with periodontitis could not be explained by confounding.

Periodontal status of diabetics compared with nondiabetics: a meta-analysis

BACKGROUND

This meta-analysis was conducted to assess the association between diabetes mellitus and periodontal diseases by comparing the extent and severity of periodontal diseases between diabetics and nondiabetics.

METHODS

A literature search was performed using MEDLINE database for published studies from January 1970 through October 2003 with manual search for references in relevant studies. This meta-analysis was based on 18 comparative cross-sectional studies, three prospective cohort studies and baseline data of two clinical trials that compared oral hygiene, gingival and periodontal status between diabetics and nondiabetics. Heterogeneity was obvious among included studies; therefore, the analysis using random-effects model was conducted.

RESULTS

This study demonstrated that diabetics had significantly worse oral hygiene as measured by the average of plaque index (P1I), higher severity of gingival disease as measured by the average of gingival index (GI) and higher severity of periodontal disease as measured by the average of probing pocket depth (PPD) and clinical attachment loss (CAL). However, diabetics had similar extent of oral hygiene, gingival and periodontal disease as measured by percentages of surfaces or sites with specific scores of P1I, GI, bleeding on probing (BOP), PPD and CAL.

CONCLUSIONS

Diabetics had a significantly higher severity but the same extent of periodontal disease than nondiabetics.

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.

[Study of the oral manifestations in diabetic children and their correlation variables]

Because children with type 1 diabetes (DM) are prone to diseases of the buccal cavity, in this transversal study we investigate the prevalence of dental caries, gingivitis and buccal alterations in 26 patients (16F/10M; average age: 10.3 years) from the Diabetic Children's Group at the Federal University Hospital of Santa Catarina, to verify possible correlations among the following variables: index of decayed, missing or filled permanent or deciduous teeth [DMFT or dmft], index of visible plaque [IVP], index of gum bleeding [IGB], dental calculi, gum recession, tongue abnormalities, xerostomia, burning sensation of the mucosa, age at DM diagnosis, administration of insulin; occurrence of DM-related complications; glycemia and glycosilated hemoglobin [GH]. The most frequent alterations were dental calculi (42.3%), xerostomia (38.5%), burning sensation (11.5%), and gum recession (7.7%). The median indices for DMFT/dmft, IVP and IGB were 2.0, 27.21% and 10.91%, respectively. Only age and the level of GH were significantly correlated to IVP (r2 = 0.61), whereas the IVP and hypoglycemia correlated to IGB (r2 = 0.63). We conclude that the older the patient and the higher the GH level, the higher the IVP; whereas the higher the IVP and the less frequent the crisis of mild hypoglycemia, the higher the IGB.

Role of smoking and HbA1c level in periodontitis among insulin-dependent diabetic patients

OBJECTIVES

The aim was to analyse the role of smoking and HbA1c level in attachment loss (AL) and probing depths (PDs) among insulin-dependent diabetic patients. MATERIAL AND-METHODS: The study subjects were selected from a group of 149 insulin-dependent diabetic patients and included 64 patients (39 men and 25 women) aged 30 years or older. Data were obtained from patient records and by clinical examination. The outcome variables were the number of sites with AL and PDs of 5-9 mm. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated using Poisson regression models. RR was adjusted for the number of teeth, dental calculus and age.

RESULTS

RR for AL among the smokers was 4.15 (95% CI: 2.30-7.63) and that for PD among the smokers was 7.96 (95% CI: 4.91-13.19). HbA1c was not related to AL or PD. Among smokers with HbA1c > 8.5, RR for AL was 12.34 (95% CI: 4.14-39.35), but RR was not elevated for PD.

CONCLUSIONS

It can be concluded that the poor metabolic control together with smoking is extremely detrimental for AL.

Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population

OBJECTIVE

We investigated the association between glycemic control of type 2 diabetes mellitus (type 2 DM) and severe periodontal disease in the US adult population ages 45 years and older.

METHODS

Data on 4343 persons ages 45-90 years from the National Health and Nutrition Examination Study III were analyzed using weighted multivariable logistic regression. Severe periodontal disease was defined as 2 + sites with 6 + mm loss of attachment and at least one site with probing pocket depth of 5 + mm. Individuals with fasting plasma glucose > 126 mg/dL were classified as having diabetes; those with poorly controlled diabetes (PCDM) had glycosylated hemoglobin > 9% and those with better-controlled diabetes (BCDM) had glycosylated hemoglobin <or= 9%. Additional variables evaluated in multivariable modeling included age, ethnicity, education, gender, smoking status, and other factors derived from the interview, medical and dental examination, and laboratory assays.

RESULTS

Individuals with PCDM had a significantly higher prevalence of severe periodontitis than those without diabetes (odds ratio = 2.90; 95% CI: 1.40, 6.03), after controlling for age, education, smoking status, and calculus. For the BCDM subjects, there was a tendency for a higher prevalence of severe periodontitis (odds ratio = 1.56; 95% CI: 0.90, 2.68).

CONCLUSION

These results provide population-based evidence to support an association between poorly controlled type 2 diabetes mellitus and severe periodontitis.

Assessment of periodontal treatment needs among adults with diabetes in Finland

OBJECTIVES

People with diabetes have a high risk for periodontal disease, which can be considered one of the complications of diabetes. We evaluated periodontal treatment needs using the Community Periodontal Index of Treatment Needs (CPITN) in relation to diabetes-related factors and oral hygiene.

DESIGN

The sample consisted of 120 dentate diabetics, all of whom were regular patients at the Salo Regional Hospital Diabetes Clinic. The nurses, who interviewed the patients, collected data on duration and type of diabetes, complications, and HbA1c level. Clinical periodontal examination included identification of visible plaque, the presence of calculus and use of the CPITN.

RESULTS

The CPITN score 3 was the most prevalent. According to the logistic regression model, poor metabolic control was significantly related to pathologic pockets. No significant association was found between diabetes-related factors and the highest individual CPITN score of 4, which was, in turn, significantly associated with extensive calculus.

CONCLUSIONS

Excessive periodontal treatment needs found, indicate that current dental care may be insufficient in adults with diabetes. Oral health among high-risk groups, especially those with poor metabolic control, should be promoted by collaboration between dental and health care professionals involved in diabetes care.

Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

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

Localized aggressive periodontitis in a patient with type 1 diabetes mellitus: a case report

BACKGROUND

Poor metabolic control of diabetes mellitus (DM) has often been associated with the severity of periodontal disease. The aim of this report is to present a 9-year-old female with localized aggressive periodontitis who had a history of type 1 DM and the outcome of her treatment.

METHODS

The patient had received medical, clinical, and radiographic periodontal examinations. Peripheral blood analysis was done as well. She had non-surgical periodontal treatment, and medical management of her diabetes was performed at the same time. She was followed longitudinally for 5 years.

RESULTS

Medical examination revealed no pathological findings except for growth retardation. Laboratory tests showed that she had poor metabolic control, with 497 mg/dl fasting blood glucose and 15.6% HbA1c. The random migration and neutrophil chemotaxis were significantly reduced. Periodontal treatment and metabolic control of her diabetes resulted in significant improvement in her periodontal condition. No incipient periodontal breakdown was observed around the teeth after 5 years from baseline.

CONCLUSIONS

This report proves the efficiency of periodontal therapy in the prevention of future periodontal breakdown in a systemically compromised patient. It seems that in certain individuals who are predisposed to the aggressive forms of periodontitis, clinical and medical examinations and intervention to the systemic condition, in combination with periodontal treatment, are important in the management of these individuals.

Influences of systemic diseases on periodontitis in children and adolescents

Systemic diseases affecting the host response as primary immunodeficiencies or secondary defects caused by lack of nutrients or changes in the local tissues are very often accompanied by early-onset prepubertal periodontitis. Local treatment in combination with systemic antibiotics may in milder forms improve the situation, but in many cases the success is questionable and premature loss of teeth occurs. Since the genetic basis of many of the diseases has been identified, future developments permit the correction of at least some of these defects by gene therapy.

Early-onset periodontitis

In 1993, the 1st European Workshop on Periodontology explicitly recognized that there was insufficient knowledge to differentiate truly different forms of periodontal disease from differences in the presentation/severity of the same disease. In spite of recent progress in our understanding of periodontal diseases, the issue is far from having been resolved. Classification of periodontal diseases, therefore, remains based upon the definition of specific clinical syndromes. Early-onset periodontitis (EOP) is one such syndrome and comprises a group of pathological conditions leading to loss of periodontal tissues early in life. The notion that classifies periodontitis syndromes as "early-onset" or "adult" is primarily epidemiological in nature and is based on the observation that periodontitis is rather infrequent in children and young adults. Nevertheless, considerable epidemiological evidence indicates that periodontitis does affect children and young adults to a level of severity that may lead to premature exfoliation of primary and/or permanent teeth. Clinical presentation of periodontitis early in the life of an individual is thought to indicate that the etiologic agents have been able to cause considerable tissue damage over a relatively short period of time. It also implies either infection with highly virulent bacteria and/or a highly susceptible subject. The purpose of this review is to discuss the criteria generally utilized to classify EOP, provide the rationale to designate EOP as a distinct disease entity, and to review the evidence justifying a subclassification into particular subgroups of EOP.

The pathogenesis of periodontal diseases

This informational paper was prepared by the Research, Science, and Therapy Committee of The American Academy of Periodontology, and is intended for the information of the dental profession. The purpose of the paper is to provide an overview of current knowledge relating to the pathogenesis of periodontal diseases. The paper will review biological processes thought to provide protection against periodontal infections. It will further discuss the mechanisms thought to be responsible for both overcoming and subverting such protective mechanisms and those that lead to destruction of periodontal tissues. Since an understanding of pathogenic mechanisms of disease is one foundation upon which new diagnostic and therapeutic modalities are based, the practitioner can use this information to help make decisions regarding the appropriate application of such new modalities in patient care settings.

HLA-DR alleles are associated with IDDM, but not with impaired neutrophil chemotaxis in IDDM

Insulin-dependent diabetes mellitus (IDDM) is a risk factor for periodontitis. Depressed neutrophil chemotaxis has been demonstrated in IDDM and in early-onset periodontitis (EOP). HLA-DR antigens are associated with both IDDM and periodontitis. This investigation sought to determine an association of HLA-DR3, -DR4, and -DR53 with impaired neutrophil chemotaxis in an IDDM sample. The neutrophil chemotaxis index of 41 diabetics and 27 controls was determined by a modified Boyden chamber method, and certain class II HLA genotypes were determined by polymerase chain-reaction amplification of genomic DNA by means of sequence-specific primers (PCR-SSP). The mean chemotaxis index of the diabetics was significantly less than that of the controls (p < or = 0.02). HLA-DR3 (p < or = 0.002), -DR4 (p < 0.003), and -DR53 (p < or = 0.001) were associated with IDDM. Neutrophil chemotaxis and glucose metabolism were not significantly correlated. None of the HLA-DR alleles was associated with impaired neutrophil chemotaxis. Therefore, the neutrophil chemotaxis defect of IDDM appears to be independent of these HLA-DR-associated genes.

Healing response to non-surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological, and immunologic results

The aim of the present study was to monitor clinical, microbiological, medical, and immunological effects of non-surgical periodontal therapy in diabetics and healthy controls. 20 IDDM (insulin dependent, n = 7) or NIDDM (non-insulin dependent, n = 13) diabetic patients (median duration 11.5 years, range of HbA1C: 4.4-10.6%) with moderate to advanced periodontal disease and 20 matched healthy control patients, were subjected to supragingival pretreatment and subsequent subgingival therapy. Periodontal examinations (API, PBI, BOP, PPD, PAL), microbiological examinations (culture), medical routine examinations, and immunological examinations (oxidative burst response of PMNs to TNF-alpha and FMLP) were performed at baseline, 2 weeks after supragingival, and 4 months after subgingival therapy. 4 months after completion of non-surgical therapy, the following compared to baseline significant (p < or = 0.05) changes (delta) of clinical parameters (median) were found in diabetic patients versus control patients: deltaAPI (30.4% versus 36.3%), deltaPBI (22.9% versus 24.2%), deltaBOP (39.5% versus 46.9%). The median % per patient of pockets with PPD > or = 4 mm decreased from 41.9% to 28.3% in diabetics, and from 41.6% to 31.8% in controls. Microbiologically, similar reductions of periopathogenic bacteria were found in diabetics and controls. Neither periodontal data nor the oxidative burst response of PMNs showed any significant difference (p > 0.05) between diabetics and control patients. In this study, periodontal therapy had no significant influence on medical data of diabetics. In conclusion, this study indicates that metabolically well-controlled diabetics might respond to non-surgical periodontal therapy as well as healthy control patients.

Periodontal status and subgingival microbiota of insulin-dependent juvenile diabetics: a 3-year longitudinal study

This study examined for 3 years the changes in periodontal status and the possible correlations with selected subgingival microbiota and diabetic conditions in a group of 16 insulin-dependent diabetes mellitus (IDDM, JD) patients as compared with their 16 healthy cohabiting siblings (HS). JD patients were monitored every 3 months for levels of glycosylated hemoglobin (HbA1C). Clinical and microbiological parameters were measured 6 weeks before drawing blood to determine levels of HbA1C. Periodontal parameters were measured at baseline (TO), year 2 (T2), year 3 (T3) and included: probing depth (PD), attachment level (AL), sulcus bleeding index (SBI), and plaque index (PI). Two sites in each patient were selected for microbial samples: a mesio-facial aspect of the maxillary right first molar (defined as constant site, CS) and a site with the greatest probing depth (defined as deepest site, DS). Microbial samples were analyzed by culture techniques. No significant differences in clinical parameters were found between diabetics and healthy siblings at any examination. The SBI in the non-diabetic group at T2 and at T3 was significantly lower than at baseline. PD and AL of constant sites in the diabetic group at T3 were significantly higher than baseline. There was a significant increase in Prevotella intermedia at T3 as compared with baseline for deepest sites in the diabetic group. Cluster analysis revealed, in a former study, two clusters (IV and V) at baseline which were significantly different from the overall mean regarding composition of Porphyromonas gingivalis and Capnocytophaga spp. They were not significantly different for periodontal parameters from TO to T3. These data would suggest no significant differences in clinical parameters between the diabetics and non-diabetic siblings throughout this 3-year longitudinal study.

Morphometric analysis of cellular and vascular changes in gingival connective tissue in long-term insulin-dependent diabetes

This study examined cellular and vascular changes in gingival connective tissue samples by stereologic point-counting procedures and interactive digital analyzing systems in long-term insulin-dependent diabetes mellitus patients. Gingival connective tissue capillaries representing a clinically healthy sulcus with no evidence of periodontal disease at the site of biopsy were studied in 29 patients with diabetes. Based upon their long-term medical records, 19 were identified as having poorly controlled (PIDD) and 10 as controlled insulin-dependent diabetes mellitus (CIDD). Ten nondiabetic, age- and gender-matched individuals served as controls. Thirty-nine biopsies were processed for light microscopy, and the blood vessel area was analyzed using an interactive digital analyzing system; 9 gingival biopsies, 5 diabetic and 4 controls, were processed for morphometric electron microscopic analysis. For each individual, site-specific recordings were made for the plaque index, bleeding index, probing depth, loss of attachment, and radiographic loss of interproximal alveolar bone. No evident signs of periodontitis occurred at the biopsy sites. For each PIDD patient, respective volumetric and numeric densities of cellular components including fibroblasts, neutrophilic granulocytes, monocyte/macrophages, mast cells, lymphocytes, blast cells, and plasma cells were recorded in the inflamed connective tissue (ICT). Non-cellular components such as collagen fibers and blood vessels were also recorded. PIDD patients had elevated plasma cell levels relative to controls and they appeared also to have a decreased collagen fiber density. In addition, fibroblasts occupied less volume in the ICT of PIDD patients than in controls. PIDD patients had the largest mean area of cross-section of the blood vessels, but this difference was not statistically significant (P > or = 0.211; t-test). No specific characteristics of ICT or vascular changes were detectable in adult well-controlled long-term diabetics under similar plaque conditions. Swollen and proliferated endothelial cells were frequently found in PIDD patients and the mean distance from the lumen to the outer border of basement membrane was greater in the PIDD than in the controls (P < 0.001; t-test). Overall, our findings that cellular, vascular, and connective tissue changes indicative of increased catabolism rather than anabolism detected in gingiva are especially associated with poorly controlled long-term insulin-dependent diabetes.

Manifestations of insulin-dependent diabetes mellitus in the periodontium of young Brazilian patients. A 10-year follow-up study

Eight female and 3 male patients from a group of 30 patients studied 10 years earlier and who had received no periodontal treatment during this period, in order to evaluate the progression of untreated periodontal disease in patients with insulin-dependent diabetes mellitus, were evaluated in terms of plaque accumulation, gingival inflammation, probing depth, and alveolar bone loss. The total number of dental surfaces that presented clinically detectable plaque deposits increased significantly (29% to 43%; P < 0.01; chi 2 = 46.36). Site-specific comparisons for plaque index between studies showed a significant variation (P < 0.01) in the upper arch only for palatal surfaces and in the lower arch for the buccal and lingual surfaces. The total dental surfaces with inflamed surrounding gingiva increased from 11% to 33% in this study (P < 0.01; chi 2 = 175.78). Site-specific comparison for gingival index showed a significant variation for all upper surfaces, while such difference for the lower arch was significant only for the buccal and lingual surfaces. The arithmetic means for the probing depth for the upper buccal, upper palatal, lower buccal, and lower lingual surfaces increased significantly (P < 0.01). The arithmetic means of alveolar bone loss also increased significantly for the upper posterior and lower regions (P < 0.01) and for the upper anterior and lower anterior regions (P < 0.05). The correlation between age and probing depth was significant only for the upper palatal region (P < 0.01). The correlation between age and bone loss was significant only for the upper posterior region (P < 0.05). The results of this follow-up study suggest that despite little variation in plaque accumulation, gingival inflammation, probing depth, and bone loss increased after a 10-year interval in patients who had received no periodontal treatment during this period.

Children, adolescents and periodontal diseases

OBJECTIVES

This manuscript attempts to critically review current literature regarding the natural history, aetiology and pathogenesis of the common periodontal diseases to affect children and adolescents. The logic behind the emergence of a new classification in the early 1990s is explained and potential problems with the interpretation of such systems outlined.

DATA SOURCES

The manuscript focuses upon recent developments, reported in the international periodontal literature, aimed at unraveling the molecular basis for this group of diseases. The concept of one disease type progressing with time to another disease within the same individual is discussed, and early data presented that indicate the possibility of microbial transmission from deciduous to permanent dentition's within a subject.

CONCLUSIONS

It is concluded that differing classification systems for adolescent and childhood periodontal diseases may lead to confusion within the dental profession, unless the clinical and molecular basis for such diseases is fully understood. Further advances in basic research using molecular biology tools should assist in our understanding of the aetiopathology at a molecular level and hopefully lead to the development of new treatment strategies.

The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus

Gingival health (bleeding on probing) and oral hygiene (plaque percent) were assessed in 2 groups of children and adolescents with insulin-dependent diabetes mellitus (IDDM). 1st study group included 12 newly diagnosed diabetic children and adolescents (age range 6.3-14.0 years, 5 boys and 7 girls). They were examined on the 3rd day after initial hospital admission and at 2 weeks and 6 weeks after initiation of insulin treatment. Gingival bleeding decreased after 2 weeks of insulin treatment (37.8% versus 19.0%, p < 0.001, paired t-test), and remained at the same level when examined 1 month later while glucose balance was excellent. Another group (n = 80) of insulin-dependent diabetic children and adolescents (age range 11.7-18.4 years, 44 boys and 36 girls) with a mean duration of diabetes 6.0 years (range 0.3-15.0 years) were examined 2x at 3-month intervals. Subjects with poor blood glucose control (glycosylated haemoglobin, HbA1, values over 13%) had more gingival bleeding (46.3% on examination 1, 41.7% on examination 2) than subjects with HbA1 values less than 10% (mean gingival bleeding 35.2% and 26.9%, respectively) or subjects with HbA1 values between 10 to 13% (mean gingival bleeding 35.6% and 33.4%, respectively). Differences were significant on both examinations (p < 0.05, Anova), and remained significant after controlling the groups for differences in age, age at the onset of diabetes, duration of diabetes and pubertal stage (Ancova). Results were not related to differences or changes in dental plaque status, supporting the concept that imbalance of glucose metabolism associated with diabetes predisposes to gingival inflammation. An increase in gingival bleeding in association with hyperglycaemia suggests that hyperglycaemia-associated biological alterations, which lower host resistance toward plaque, have apparently taken place. Consequently, although not all gingivitis proceeds into a destructive periodontal disease, prevention of plaque-induced gingival inflammation should be emphasised, particularly in children and adolescents with poorly controlled diabetes.

Periodontal diseases: epidemiology

1. The interpretation of epidemiological data of periodontal disease is difficult, due to inconsistencies in the methodology used. It is not possible, therefore, to accurately assess if the prevalence of the periodontal diseases shows a world-wide decline. As long as the disease is assessed through accumulated clinical attachment loss, retention of the natural dentition in older ages entails increased prevalence in these cohorts. Contemporary epidemiological studies should ideally employ full-mouth examination of the periodontal tissues. Partial recording estimates are generally biased, especially when the prevalence of the disease is low. 2. Early-onset periodontitis is infrequent in all populations. Adult periodontitis is rather prevalent; however, advanced disease affects limited subfractions of the population (probably less than 10 to 15%). Although prevalence figures vary with race and geographic region, in most cases, the progression pattern of the disease seems compatible with the retention of a functional dentition throughout life. 3. Of a plethora of behavioral and environmental risk markers identified by multi-variate analysis, smoking and presence of certain subgingival microorganisms have been proven to be true risk factors. The same holds true for diabetes mellitus, a systemic condition that confers a risk for periodontal disease which is independent of the effect of other significant factors. 4. In certain cases, periodontal infections appear to have a systemic impact on the host. Most recent data indicate that periodontal disease may confer risk for coronary heart disease and pre-term low birth weight.