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

Periodontitis and implant complications in diabetes

Epidemiologic evidence indicates that periodontitis is more frequent in patients with uncontrolled diabetes mellitus than in healthy controls, suggesting that it could be considered the "sixth complication" of diabetes. Actually, diabetes mellitus and periodontitis are two extraordinarily prevalent chronic diseases that share a number of comorbidities all converging toward an increased risk of cardiovascular disease. Periodontal treatment has recently been shown to have the potential to improve the metabolic control of diabetes, although long-term studies are lacking. Uncontrolled diabetes also seems to affect the response to periodontal treatment, as well as the risk to develop peri-implant diseases. Mechanisms of associations between diabetes mellitus and periodontal disease include the release of advanced glycation end products as a result of hyperglycemia and a range of shared predisposing factors of genetic, microbial, and lifestyle nature. This review discusses the evidence for the risk of periodontal and peri-implant disease in diabetic patients and the potential role of the dental professional in the diabetes-periodontal interface.

The effect of diabetes on the tensile bond strength of a restorative dental composite to dentin

This study was performed to evaluate the effect of diabetes mellitus (DM) on the tensile bond strength (TBS) of dental composite resin bonding to enamel and dentin of extracted human teeth. Thirty caries-free human premolar teeth (10 from type 1 DM (D1), 10 from type 2 DM (D2), and 10 from non-diabetic individuals (control)) were wet ground and polished to obtain flat surfaces of dentin (n = 10). 37% phosphoric acid was used to etch dentin specimens for 15 s. After the application of the adhesive system, the composite resins were applied and cured for 20 s. Then, specimens were subjected to TBS testing by Universal Testing Machine (1 mm/min). One specimen from each group was prepared and observed under a scanning electron microscope (SEM) and a dot map was generated. Data were analyzed by ANOVA and post hoc Tukey tests (α = 0.05). The TBS values were significantly higher in the control group compared to the D1 and D2 groups (P < 0.05). Between DM groups, D2 values were significantly higher than those in the D1 group. Unlike DM groups, the zigzag fracture pattern was only noticed in the control group. DM adversely affected the TBS of dental composite resins to dentin; this negative effect is more exaggerated by type 1 DM than type 2 DM.

Oral health and halitosis among type 1 diabetic and healthy children

AIM

To evaluate the oral health status, oral health related habits and halitosis of children with and without type 1 diabetes.

MATERIALS AND METHODS

In this study the oral health status of children with and without type 1 diabetes were evaluated by using different indices (dmft/DMFT, International Caries Detection and Assessment System(ICDAS) II, pufa, gingival and periodontal indices). Halitosis was determined by organoleptic assessment and sulfur monitoring.

RESULTS

One hundred children with the age range between 6-13 years, 50 type 1 diabetics (24 boys,26 girls) with mean age (±sd) of 10.3 ± 2.1 years and 50 healthy (30 boys, 20 girls) with mean age (±sd) of 9.9 ± 1.5 years, participated in the study. The median values of dmft and dmfs was lower in children with type 1 diabetes, while for DMFT and DMFS indices were similar with the healthy group. Cavitated caries lesions were observed in 60.0% of children with diabetes and in 58.0% of healthy children. According to the ICDAS II index, 42.0% of children with diabetes and 56.0% of healthy children had severe decay. The mean plaque index was statistically significantly less in diabetic children (p = 0.04). In 12.0% of children with type 1 diabetes and in 18.0% of healthy children, volatile sulfur compounds (VSC) were determined to be ≥150 ppb and the most diagnosed score was 1 in both groups. In diabetic children with the cut off value of 7.5% HbA1c, there was no statistically significant difference in oral health indices results and VSC scores.

CONCLUSION

Findings of the present study are insufficient to support a significant effect of diabetes on increasing the risk of oral and periodontal diseases. Nonetheless, it is important to emphasize the importance of oral and dental health, regular oral care and dental visits both to the patients with type 1 diabetes and their parents.

Integrated hypothesis of dental caries and periodontal diseases

This review considers an integrated hypothesis of dental caries and periodontal diseases that builds on theoretical ecological principles. The backbone of the hypothesis is based on the dynamic stability stage of the oral microbiota, at which intrinsic (mainly saliva and gingival crevicular fluid) and bacterial (mainly metabolic) resilience factors maintain ecological dynamic stability, compatible with clinical health. However, loss of intrinsic resilience factors and/or prolonged changes in the availability of microbial metabolic substrates may shift the ecological balance of the microbiota into either saccharolytic (acidogenic) or amino acid-degrading/proteolytic (alkalinogenic) stages, depending on the nature of the predominant substrates, leading to clinical diseases. Therefore, to maintain and restore the dynamic stability of the oral microbiota, it is necessary to control the drivers of disease, such as salivary flow and influx of bacterial nutrients into the oral cavity. Contrary to conventional wisdom, excessive intake of fermentable carbohydrates may contribute to inflammation in periodontal tissues resulting from hyperglycaemia. An integrated hypothesis emphasizes that both dental caries and periodontal diseases originate in the dynamic stability stage and emerge in response to nutritional imbalances in the microbiota. Periodontal diseases may belong to the sugar driven inflammatory diseases, similar to diabetes, obesity, and cardiovascular diseases.

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.

Saliva Proteomics Analysis Offers Insights on Type 1 Diabetes Pathology in a Pediatric Population

The composition of the salivary proteome is affected by pathological conditions. We analyzed by high resolution mass spectrometry approaches saliva samples collected from children and adolescents with type 1 diabetes and healthy controls. The list of more than 2000 high confidence protein identifications constitutes a comprehensive characterization of the salivary proteome. Patients with good glycemic regulation and healthy individuals have comparable proteomic profiles. In contrast, a significant number of differentially expressed proteins were identified in the saliva of patients with poor glycemic regulation compared to patients with good glycemic control and healthy children. These proteins are involved in biological processes relevant to diabetic pathology such as endothelial damage and inflammation. Moreover, a putative preventive therapeutic approach was identified based on bioinformatic analysis of the deregulated salivary proteins. Thus, thorough characterization of saliva proteins in diabetic pediatric patients established a connection between molecular changes and disease pathology. This proteomic and bioinformatic approach highlights the potential of salivary diagnostics in diabetes pathology and opens the way for preventive treatment of the disease.

The influence of glycemic control on the oral health of children and adolescents with diabetes mellitus type 1

OBJECTIVE

To evaluate the influence of disease control, expressed by the mean values of glycated hemoglobin (HbA1c), in the oral health of children and adolescents with diabetes mellitus type 1 (T1DM).

SUBJECTS AND METHODS

A cross sectional study involving 87 children and adolescents (59 girls), 10 ± 2.6 years old. The participants were divided into three groups: HbA1c ≤ 8%, 8% < HbA1c ≤ 10% and HbA1c > 10%. The duration of the disease, age and average HbA1c were obtained from their medical records. Oral health was evaluated according to the following indexes: Simplified Oral Hygiene Index (OHI-S); Community Periodontal Index (CPI); Decayed, Missing or Filled Teeth Index (DMFT/dmft) for permanent and deciduous teeth; and the stimulated salivary flow rate (SSFR).

RESULTS

The median SSFR was 1.1 mL/min in the group with HbA1c ≤ 8%, 0.7 mL/min in the intermediary group and 0.6 mL/min in the HbA1c > 10% group. A significant decrease in salivary flow was observed with an increase in HbA1c (p = 0.007). The DMFT/dmft and CPI indexes were higher in individuals with higher HbA1c values. More caries-free individuals were found in the group with HbA1c ≤ 8% compared to those with HbA1c > 10%. The group with HbA1c > 10% exhibited more caries and bleeding gums than the other groups. HbA1c values in girls were higher than in boys.

CONCLUSION

Children and adolescents with unsatisfactory glycemic control, represented by higher HbA1c concentrations, exhibited a higher frequency of caries and gingivitis, and a reduction in salivary flow.

Periodontitis and type II diabetes: a two-way relationship

For many years an association between diabetes and periodontitis has been suspected. In more recent times this relationship has been suggested to be bidirectional with each condition being able to influence the other. In this review the two-way relationship between diabetes and periodontitis is considered. For this narrative review a very broad search strategy of the literature was developed using both EMBASE and MEDLINE (via PubMed) databases. The reference lists from the selected papers were also scanned, and this provided an additional source of papers for inclusion and further assessment. The data available suggest that diabetes is a risk as well as a modifying factor for periodontitis. Individuals with diabetes are more likely to have periodontitis and with increased severity when diabetes is uncontrolled/poorly controlled. Possible mechanisms of how diabetes affects periodontitis include adipokine-mediated inflammation, neutrophil dysfunction, uncoupling of bone and advanced glycation end-products-receptor for advanced glycation end-products interaction. Evidence is accruing to support how periodontitis can affect diabetes and complications associated with diabetes. There is some evidence demonstrating that periodontal therapy can result in a moderate improvement in glycaemic control. Available evidence indicates that diabetes and peridontitis are intricately interrelated and that each condition has the capacity to influence clinical features of each other.

An ignored cause of inflammation in patients undergoing continuous ambulatory peritoneal dialysis: periodontal problems

AIM

We aimed to assess whether there is a significant relation between periodontal health status and inflammation in uremic patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and also to reveal the efficiency of periodontal treatment in patients with various degrees of periodontal problems.

PATIENTS AND METHODS

Overall, 68 patients undergoing CAPD were included in the study. Clinical indices and measurements were obtained at baseline and panoramic radiographies were used for the diagnosis. According to the baseline values, patients were stratified into four groups according to the severity of periodontal problems as follows: healthy/gingivitis, slight-to-moderate, and severe periodontitis. A control examination was performed 3 months after the periodontal treatment for only 43 patients. Clinical and laboratory parameters before and after treatment were compared.

RESULTS

The frequency of periodontal disease was found to be high in uremic patients on CAPD. The frequency and severity of periodontitis was also found to be significantly (p < 0.01) higher in patients with high sensitive C-reactive protein levels and longer duration of peritoneal dialysis (p < 0.01). In addition, the periodontitis rate was found to be higher in patients with cardiovascular disease (p < 0.05) and diabetes mellitus (p < 0.01).

CONCLUSION

A meticulous periodontal examination should be a routine part of management of the uremic patients on CAPD because periodontal disease could be one of the hidden sources of unexplained inflammatory status.

Rehabilitative considerations for dental implants in the diabetic patient

Diabetes is a serious illness that affects many people, and there are many new cases diagnosed every year in all populations around the world. Dental implant is one of the restorative methods to replace missing teeth. As implants are directly anchored into bones, they provide stability, a more natural appearance, and minimize the risk of bone resorption. Thus, today, there is a high demand of dental implants and it is inevitable to meet diabetics who request implant treatment. However, Diabetes mellitus patients may pose contraindications to dental implants because of microvascular complications leading to slower healing process after surgery. Studies have shown that dental implantation failure rate in diabetic patients is much higher than that in non-diabetic patients. This article reviews the effect of diabetes on the osseointegration of implants and the soft tissue healing. It presents the factors used in assessing the severity of diabetes and its complications, as well as considerations for rehabilitation planning in these patients. In addition, the role of antibiotic prophylaxis has been reviewed since its effect on wound healing in diabetics is controversial. Integration of these factors by the dentist can dictate whether, as well as what type of implant supported prosthesis should be given to the diabetic patient.

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.

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.

A clinical study of the relationship between diabetes mellitus and periodontal disease

The relationship between diabetes mellitus and periodontal disease is not clear, even though studied intensively. From the available data, it seemed reasonable to believe that diabetics were more susceptible to periodontal disease than non.diabetics.

AIM

The present study was to clinically evaluate the relationship of diabetes mellitus with periodontal disease along with various parameters.

MATERIALS AND METHODS

Fifteen hundred patients with diabetes mellitus were examined. A thorough oral examination was carried out and relevant history was recorded for all the patients.

RESULTS

Results indicated that the prevalence of periodontal disease in diabetic patients was 86.8%.

CONCLUSION

It can be concluded that poorer the glycemic control, and longer the duration of diabetes, the greater will be the prevalence and severity of periodontal disease.

Oral Health Knowledge and Behaviors among Adolescents with Type 1 Diabetes

Early onset and more advanced periodontal disease has been reported for children with diabetes. We surveyed oral health knowledge, attitudes, and behaviors among adolescents with diabetes in order to inform potential intervention strategies. Study subjects were youth (ages 12–19 years) with type 1 diabetes (N = 90) participating in a cohort study investigating determinants of periodontal disease at a regional pediatric diabetes specialty clinic. Over 90% of the youth had been instructed on how to brush and floss and had preventive dental care in the past year. However, 44% knew that periodontal disease is associated with diabetes and 32% knew that it can start in childhood with bleeding gums. Despite being at high risk for developing periodontal disease, the mean toothbrushing frequency was once per day and 42% did not floss. Significant opportunity exists for improving periodontal disease knowledge and adoption of preventive oral hygiene behaviors in adolescents with diabetes.

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.

Diabetes mellitus promotes periodontal destruction in children

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Vascular endothelial growth factor (VEGF) levels of gingiva and gingival crevicular fluid in diabetic and systemically healthy periodontitis patients

It has been demonstrated that diabetes mellitus (DM) may have an inductive effect on the vascular endothelial growth factor (VEGF) levels of periodontium during periodontal disease. The aim of this study is to confirm this phenomenon, investigating whether it is also valid for diabetic periodontitis patients under good metabolic control. Sixteen type II DM patients, all with a glycosylated hemoglobin (HbA1c) value less than 7 (test), and 15 systemically healthy (control) chronic periodontitis patients were included in the study. The VEGF concentrations in the gingival supernatants and gingival crevicular fluid (GCF) samples of the study groups were measured by enzyme-linked immunosorbent assay. The data were analyzed by Student's t test in statistical means. The VEGF levels were significantly higher in the gingival supernatants of the test group (55.89 +/- 8.11 pg/ml) than that of the control group (24.81 +/- 2.04 pg/ml; p < 0.01). However, there was no statistically significant difference in the VEGF levels of GCF between the study groups (38.96 +/- 4.89 pg/ml in the test and 32.20 +/- 4.02 pg/ml in the control group; p > 0.05). Our study confirms that DM affects the VEGF levels of periodontal soft tissues in periodontal disease, and our results also suggest that this effect may not be influenced by the metabolic control of DM.

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.

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.

Potential impact of subject-based risk factor control on periodontitis

AIMS

To assess the potential impact of the control of subject-based modifiable risk factors on periodontitis.

BACKGROUND

Cross-sectional and longitudinal data from epidemiological research indicate that risk factors can be identified and, if modified, may improve both periodontal conditions and the outcome of treatment.

MATERIAL AND METHODS

A search was conducted to identify factors involved in the etiology and pathogenesis of periodontal diseases. The factors identified were separated into modifiable and non-modifiable, and control of the subject-based modifiable risk factors were further analyzed.

RESULTS

The analysis was limited to the influence of the control of the remaining modifiable subject-based risk factors. It was observed that most of the subject related risk factors were hitherto not validated in controlled intervention studies. Therefore, the evidence for the efficacy of risk factor control had to be based on results from cohort studies. While the control of most of the modifiable risk factors for periodontitis was not tested, some evidence suggested that smoking cessation may retard the progression of periodontitis.

CONCLUSIONS

Although only limited evidence was available, it appeared reasonable to suggest that second to the removal of the bacterial biofilm, smoking cessation was the most important measure in the management of periodontitis.

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.

Periodontal Health, Salivary Status, and Metabolic Control in Children with Type 1 Diabetes Mellitus

BACKGROUND

The aim of this study was to determine whether detectable periodontal destruction and alterations in the salivary status were present with duration of diabetes in children with type 1 insulin-dependent diabetes mellitus (type 1 DM) as compared to healthy controls.

METHODS

Sixteen newly diagnosed children with DM (group 1), 16 children with type 1 DM of long duration (group 2), and 16 healthy children (group 3) participated in the study. Periodontal health was assessed by plaque index, gingival index, bleeding on probing, and periodontal probing depths. The flow rate, pH, buffering capacity, and peroxidase activities of stimulated saliva were determined. The data were analyzed by Kruskall-Wallis, Student t test, and Pearson's correlation analysis.

RESULTS

The mean values for fasting blood glucose levels for the diabetic groups were significantly higher than for the controls. The mean values for salivary buffering capacities and salivary pH from the diabetic groups were significantly lower than for the controls. The plaque index values for the diabetic groups were significantly higher than for the controls. The mean gingival index value for group 1 was significantly lower than for group 2. The mean periodontal probing depths for group 1 were similar to those of the non-DM controls, but the mean periodontal probing depths for group 2 were significantly greater than for both the non-DM controls and group 1. Group 1 had significantly greater bleeding on probing scores than did the other groups (P < 0.05).

CONCLUSION

The glycemic status of the diabetic subjects affects the periodontal probing depths, salivary pH, buffering capacity, and peroxidase activity.

Evidence of autoantibodies to glutamic acid decarboxylase in oral fluid of type 1 diabetic patients

Circulating antibodies to glutamic acid decarboxylase (GADab) are a major indicator for autoimmune destruction of pancreatic islet cells (type 1 diabetes). Previously reported detection of GADab in oral fluid, however, was assayed by enzyme-linked immunosorbent assay (ELISA) with low diagnostic sensitivity and high non-specific binding. We re-assessed oral fluid GADab detection using a different sampling technique and a more robust assay. Type 1 diabetic subjects (n = 32; mean age +/- SD: 13.9 +/- 3.7 years) provided Orasure oral fluid and venous blood samples. Orasure collections were assayed for total immunoglobulin G (IgG), then concentrated to 1/10 of their volume using mini-centrifugal protein concentrators. All samples were assayed by a GAD65 antibody radio-immunoprecipitation method. Oral fluid antibodies were detected ( > 99th percentile of radio-binding (%counts per min (%cpm)) for seronegatives) in 10/16 seropositive subjects, with %cpm (median: 6.4%; range: 4.6-25.8) significantly greater (P < 0.001) than for seronegatives (median: 4.7%; range: 3.4-5.7). A highly significant correlation (Spearman's rho: 0.85; P<0.001) was demonstrated between %cpm of concentrates and respective serum titres for seropositive diabetics. Median IgG concentration of Orasure collections was 22.8 mg/l (range: 9.4-168.0). GADab recovery from Orasure collectors was estimated at 90%. This is the first confirmatory detection of diabetes-specific autoimmune markers in oral fluid. Acceptable correlation between concentrated oral fluid radio-binding and serum titre was achieved. Improved antibody recovery and assay re-optimisation could provide a basis for more extensive studies that may lead to an alternative non-invasive screening method for pre-clinical autoimmune diabetes.

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.

Cancrum oris in a Caucasian male with Type 2 diabetes mellitus

We describe a patient with Type 2 diabetes mellitus who developed cancrum oris requiring extensive oro-facial reconstructive surgery. There are no previous published reports of cancrum oris occurring in a Caucasian subject with no risk factors other than Type 2 diabetes.

Relationships between oral and systemic health

Oral and systemic health cannot be separated. This article addresses some established and emerging relationships that highlight the association between systemic and oral health. The physician's role requires an understanding of the effects of disease and its treatment on oral health. Also, physicians should be able to identify abnormality in the oral cavity that might be attributable to disease or be a compromising factor in the health, growth and development, or functioning of children and make a referral. Cooperation between dentist and physician can mean good overall health for children, including oral health.

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.