A review of the evidence for pathogenic mechanisms that may link periodontitis and diabetes

Rational design of multifunctional hydrogels targeting the microenvironment of diabetic periodontitis

Periodontitis is a chronic inflammatory disease and is the primary contributor to adult tooth loss. Diabetes exacerbates periodontitis, accelerates periodontal bone resorption. Thus, effectively managing periodontitis in individuals with diabetes is a long-standing challenge. This review introduces the etiology and pathogenesis of periodontitis, and analyzes the bidirectional relationship between diabetes and periodontitis. In this review, we comprehensively summarize the four pathological microenvironments influenced by diabetic periodontitis: high glucose microenvironment, bacterial infection microenvironment, inflammatory microenvironment, and bone loss microenvironment. The hydrogel design strategies and latest research development tailored to the four microenvironments of diabetic periodontitis are mainly focused on. Finally, the challenges and potential solutions in the treatment of diabetic periodontitis are discussed. We believe this review will be helpful for researchers seeking novel avenues in the treatment of diabetic periodontitis.

Tooth loss is associated with prevalent diabetes and incident diabetes in a longitudinal study of adults in Ireland

AIM

The aim of this study was to explore the relationship between periodontal status, tooth loss and diabetes among community-dwelling adults aged 50 years and over in Ireland.

METHODS

From respondents who attended a health assessment in Wave 3 of the Irish Longitudinal Study on Ageing (TILDA), an opportunistic sample was selected for an oral health examination. The oral health examination criteria were used in previous Irish surveys and WHO recommendations. For diabetes, the self-reported and objectively measured data on diabetes for the same cohort from Wave 3 to Wave 5 of TILDA was used. Multinomial regression analysis was used to evaluate the relationship between diabetes and tooth loss and tooth loss and incident diabetes, controlling for other covariates.

RESULTS

Out of the 3111 people who were offered an oral health assessment 2539 were examined. For the purposes of analysis, the adults below 50 years of age (n = 31) and those with an incomplete oral health assessment (n = 4) were omitted from the sample. The final sample consisted of 2504 people, giving a response rate of 80.5%. Among the study sample, 9.9% (n = 249) were edentate; 35.7% (n = 895) had 1-19 teeth and 54.4% (n = 1360) had ≥20 teeth. From the sample of 2504 adults, 2358 had HbA1c results and 8.4% (n = 198) of these had diabetes according to the TILDA criteria. Multinomial regression analysis showed that diabetes was associated with tooth loss. Diabetes at Wave 3 was associated with a higher rate of being edentate (PR 2.12, 95% CI 1.27-3.52) relative to having ≥20 teeth while controlling for the effect of age, gender, education level, area of residence, body mass index (BMI) and smoking. Furthermore, having 1-19 teeth at Wave 3 was associated with incident diabetes over a 4-year follow-up (OR 1.94, 1.00-3.75). There was no evidence of an association between diabetes and periodontal status as measured in this sample.

CONCLUSION

The results suggested that diabetes was associated with tooth loss and that this relationship may be bi-directional among community-dwelling adults aged 50 years and over in Ireland, but they do not support a relationship between diabetes and periodontal status in this sample.

Effect of adjuvant probiotic therapy (Lactobacillus reuteri) in the treatment of periodontitis associated with diabetes mellitus: clinical, controlled, and randomized study

OBJECTIVES

Subgingival instrumentation (SI) with probiotics may be a proposal for the treatment of periodontitis (P), for patients with type 2 diabetes mellitus (T2DM). The Lactobacillus reuteri probiotic as an adjunctive therapy in the treatment of P associated with T2DM was evaluated.

MATERIALS AND METHODS

Forty diabetic participants diagnosed with P (stage III and IV, grade B) were randomized into SI + Placebo (n = 20): subgingival instrumentation plus placebo lozenges and SI + Probi (n = 20): subgingival instrumentation plus probiotics. Probing depth (PD), gingival recession (GR), clinical attachment level (CAL), plaque index (PI), bleeding on probing (BoP), and PISA index were performed at baseline and 30, 90, and 180 days. Cytokine concentration in the gingival crevicular fluid, subgingival biofilm sample, and LDL and HDL subfractions were evaluated.

RESULTS

In the deep pockets, PD in SI + Probi showed increased values (p = 0.02) compared to SI + Placebo at 90 days. For CAL, SI + Probi showed increased values compared to SI + Placebo, with a significant difference at 30 days (p = 0.03), 90 days (p = 0.02), and 180 days (p = 0.04). At #PD ≥ 7 mm, SI + Probi had a more frequent number of sites (p = 0.03) compared to SI + Placebo only at baseline. For the PISA, SI + Probi showed a significant difference (p = 0.04) compared to SI + Placebo at 90 days. For cytokines, SI + Probi showed higher quantification than SI + Placebo for IL-10 (p < 0.001) at 90 days, IL-12 (p = 0.010) at 90 days, IL-1β (p = 0.035) at 90 days, and IL-8 (p = 0.003) at baseline. SI + Placebo showed higher quantification of IL-1β (p = 0.041) compared to SI + Probi only at 30 days. There was a reduction in all microbial complexes. SI + Probi improved LDL size (246.7 nm vs 260.4 nm; p < 0.001), while large HDL subfractions were reduced aft 180 days of treatment (24.0% vs 20.3%; p = 0.022) when compared with SI + Placebo; this response was dependent of probiotics (1.0 mg/dL vs - 6.2 mg/dL; p = 0.002).

CONCLUSION

Subgingival instrumentation improved the clinical periodontal parameters in patients with T2DM. The use of L. reuteri probiotics had no additional effects compared with the placebo; however, there was a positive effect on the lipoprotein subfraction.

CLINICAL RELEVANCE

Scientific rationale for study: subgingival instrumentation with probiotics may be a proposal for the treatment of periodontitis (P), especially for patients with type 2 diabetes mellitus (T2DM).

PRINCIPAL FINDINGS

the use of L. reuteri probiotics had no additional effects compared with the placebo; however, there was a positive effect on the lipoprotein subfraction.  Practical implications: L. reuteri as an adjunct to subgingival instrumentation may have significant therapeutic implications in dyslipidemia.

Perturbation of mitochondrial dynamics links to the aggravation of periodontitis by diabetes

Diabetes and periodontitis are prevalent diseases that considerably impact global economy and diabetes is a major risk factor of periodontitis. Mitochondrial dynamic alterations are involved in many diseases including diabetes and this study aims to evaluate their relevance with diabetes aggravated periodontitis. Sixty mice are randomly divided into 4 groups: control, periodontitis, diabetes and diabetic periodontitis. Periodontitis severity is evaluated by alveolar bone loss, inflammation and oxidative stress status. Mitochondrial structural and functional defects are evaluated by the mitochondrial fission/fusion events, mitochondrial reactive oxygen species (ROS) accumulation, complex activities and adenosine triphosphate (ATP) production. Advanced glycation end product (AGE) and Porphyromonas gingivalis are closely related to periodontitis occurrence and development. Human gingival fibroblast cells (HGF-1) are used to investigate the AGE role and lipopolysaccharide (LPS) from Porphyromonas gingivalis (P-LPS) in aggravating diabetic periodontitis by mitochondrial dynamic and function alterations. In vivo, diabetic mice with periodontitis show severe bone loss, increased inflammation and oxidative stress accumulation. Among mice with periodontitis, diabetic mice show worse mitochondrial dynamic perturbations than lean mice, along with fusion protein levels inducing more mitochondrial fission in gingival tissue. In vitro, AGEs and P-LPS co-treatment causes severe.

Emerging role of photodynamic therapy as an adjunct to nonsurgical periodontal therapy on periodontal status and glycemic control in patients with type 2 diabetes: A clinical study

Background

Periodontal disease is considered to be the sixth most common complication of diabetes mellitus (DM). Antibiotics (systemic and local) enhance the outcome of conventional mechanical debridement but frequent use of antimicrobials may develop resistance to microorganisms. To overcome this complicacy, the current study assessed the effectiveness of photodynamic therapy (PDT) in chronic periodontitis patients with type 2 diabetes when used as a combination therapy to standard periodontal therapy by assessing the various clinical and glycemic parameters.

Materials and Methods

A total of 16 known cases of chronic Periodontitis patients who were suffering from type 2 DM were allocated into two groups. The test group (n = 8) was treated with standard scaling and root planing (SRP) along with PDT while the control group was treated with SRP alone. Various clinical parameters assessed were plaque index, gingival index, pocket probing depth, clinical attachment level, and Glycated hemoglobin level at baseline and 90 days after therapy.

Results

At the end of the study, both the groups showed improvements with regard to all clinical and glycemic parameters compared to baseline. However, the test group presented statistically significant favorable results (all P < 0.05).

Conclusion

Conventional periodontal treatment aided with PDT proved to be a beneficial therapeutic measure and effective alternative in patients with chronic periodontitis with diabetes when compared with standard periodontal therapy alone.

Effect of subgingival periodontal therapy on glycaemic control in type 2 diabetes patients: Meta-analysis and meta-regression of 6-month follow-up randomized clinical trials

BACKGROUND

Periodontitis worsens the hyperglycaemia in patients with type 2 diabetes mellitus (T2DM). Subgingival instrumentation, with or without surgical access, is the gold-standard treatment for periodontitis. The aim was to summarize the evidence on the effect of subgingival instrumentation (with or without open flap) on the reduction of glycosylated haemoglobin (HbA1c).

METHODS

Nine electronic databases were searched up to 15 February 2023. Twelve randomized controlled trials with at least 6 months of follow-up were included. Studies using systemic or local-delivery antimicrobial therapies were excluded. Meta-analyses were performed using the random-effects model. The sources of heterogeneity were assessed by applying linear meta-regression. Risk of bias was assessed by RoB 2, and certainty of evidence by GRADE.

RESULTS

Eleven studies were included in the quantitative analyses (1374 patients). Subgingival instrumentation resulted in 0.29% lower HbA1c (95% confidence interval: 0.10-0.47; p = .03) compared with non-active treatment.

DISCUSSION

None of the 12 studies were assessed as having low risk of bias. The percentage of females and the time of diabetes diagnosis significantly explained the high level of heterogeneity. Subgingival periodontal therapy results in a significant and clinically relevant improvement in glycaemic control over 6 months in patients with T2DM and periodontitis. The grade of evidence was moderate.

Increased risk of periodontitis in patients with rheumatoid arthritis: A nationwide register study in Norway

AIM

To investigate the risk of periodontitis in rheumatoid arthritis (RA) patients in a nationwide register-based study.

MATERIALS AND METHODS

Patients and controls were defined using ICD-10 codes registered in the Norwegian Patient Registry (NPR), from 2011 to 2017. The 324,232 included subjects had at least one registered diagnostic code for RA (33,040 patients) or diagnostic codes for non-osteoporotic fractures or hip or knee replacement due to osteoarthritis (controls). The outcome was periodontitis, defined by codes for periodontal treatment from the Norwegian Control and Payment of Health Reimbursements Database (KUHR). Hazard ratios (HRs) were calculated for periodontitis in RA patients compared to controls. Generalized additive model in Cox regressions was estimated to visualize periodontitis occurrences as a function of number of RA visits.

RESULTS

The risk of periodontitis increased with increasing number of RA visits. RA patients having 10 or more visits during the 7-year period had a 50% increased risk of periodontitis compared to controls (HR = 1.48, 95% confidence interval [CI]: 1.39-1.59); also, in patients with assumed new RA, an even higher risk estimate was seen (HR = 1.82, 95% CI: 1.53-2.17).

CONCLUSIONS

In this register-based study in which periodontal treatment was used as a surrogate marker for periodontitis, we found an increased risk of periodontitis in RA patients, particularly those with active disease and new RA.

Periodontal Disease and Other Adverse Health Outcomes Share Risk Factors, including Dietary Factors and Vitamin D Status

For nearly a century, researchers have associated periodontal disease (PD) with risks of other adverse health outcomes such as cardiovascular disease, diabetes mellitus, and respiratory diseases, as well as adverse pregnancy outcomes. Those findings have led to the hypothesis that PD causes those adverse health outcomes either by increasing systemic inflammation or by the action of periodontopathic bacteria. However, experiments largely failed to support that hypothesis. Instead, the association is casual, not causal, and is due to shared underlying modifiable risk factors, including smoking, diet, obesity, low levels of physical activity, and low vitamin D status. Diabetes mellitus is also considered a risk factor for PD, whereas red and processed meat are the most important dietary risk factors for diabetes. Because PD generally develops before other adverse health outcomes, a diagnosis of PD can alert patients that they could reduce the risk of adverse health outcomes with lifestyle changes. In addition, type 2 diabetes mellitus can often be reversed rapidly by adopting an anti-inflammatory, nonhyperinsulinemic diet that emphasizes healthful, whole plant-based foods. This review describes the evidence that proinflammatory and prohyperinsulinemia diets and low vitamin D status are important risk factors for PD and other adverse health outcomes. We also make recommendations regarding dietary patterns, food groups, and serum 25-hydroxyvitamin D concentrations. Oral health professionals should routinely inform patients with PD that they could reduce their risk of severe PD as well as the risks of many other adverse health outcomes by making appropriate lifestyle changes.

Integration of molecular docking, molecular dynamics and network pharmacology to explore the multi-target pharmacology of fenugreek against diabetes

Fenugreek is an ancient herb that has been used for centuries to treat diabetes. However, how the fenugreek-derived chemical compounds work in treating diabetes remains unclarified. Herein, we integrate molecular docking and network pharmacology to elucidate the active constituents and potential mechanisms of fenugreek against diabetes. First, 19 active compounds from fenugreek and 71 key diabetes-related targets were identified through network pharmacology analysis. Then, molecular docking and simulations results suggest diosgenin, luteolin and quercetin against diabetes via regulation of the genes ESR1, CAV1, VEGFA, TP53, CAT, AKT1, IL6 and IL1. These compounds and genes may be key factors of fenugreek in treating diabetes. Cells results demonstrate that fenugreek has good biological safety and can effectively improve the glucose consumption of IR-HepG2 cells. Pathway enrichment analysis revealed that the anti-diabetic effect of fenugreek was regulated by the AGE-RAGE and NF-κB signalling pathways. It is mainly associated with anti-oxidative stress, anti-inflammatory response and β-cell protection. Our study identified the active constituents and potential signalling pathways involved in the anti-diabetic effect of fenugreek. These findings provide a theoretical basis for understanding the mechanism of the anti-diabetic effect of fenugreek. Finally, this study may help for developing anti-diabetic dietary supplements or drugs based on fenugreek.

Periodontal Health and Disease in the Context of Systemic Diseases

During recent years, considerable progress has been made in understanding the etiopathogenesis of periodontitis in its various forms and their interactions with the host. Furthermore, a number of reports have highlighted the importance of oral health and disease in systemic conditions, especially cardiovascular diseases and diabetes. In this regard, research has attempted to explain the role of periodontitis in promoting alteration in distant sites and organs. Recently, DNA sequencing studies have revealed how oral infections can occur in distant sites such as the colon, reproductive tissues, metabolic diseases, and atheromas. The objective of this review is to describe and update the emerging evidence and knowledge regarding the association between periodontitis and systemic disease and to analyse the evidence that has reported periodontitis as a risk factor for the development of various forms of systemic diseases in order to provide a better understanding of the possible shared etiopathogenetic pathways between periodontitis and the different forms of systemic diseases.

Dental Condition, Diet, and Glycaemic Control: Analysis of NHANES 2011-2014

OBJECTIVES

A bidirectional relationship between periodontitis and diabetes has been reported. Its mechanisms are yet to be elucidated. This study examines the interplays amongst dental conditions (periodontitis and functional dentition), diet, and glycaemic control of adults.

METHODS

Relevant data of the NHANES surveys (2011-2012 and 2013-2014) (n = 6076) were extracted, including dental examination for generalised severe periodontitis (GSP) and functional dentition, laboratory tests for haemoglobin A1c (HbA1c), and 24-hour dietary recall. Multiple regressions and path analysis were conducted to assess the association between dental conditions and glycaemic control and the mediation effect of diet.

RESULTS

Higher HbA1c value was associated with GSP (coef: 0.34; 95% CI: 0.10 to 0.58) and nonfunctional dentition (coef: 0.12; 95% CI: 0.01 to 0.24). Associations were also found between lower fibre intake (g/1000 kcal) with GSP (coef: -1.16; 95% CI: -1.61 to -0.72) and nonfunctional dentition (coef: -0.80; 95% CI: -1.18 to -0.42). Mediation effect of diet (% energy from carbohydrate and energy-adjusted fibre intake) for the association between dental conditions and glycaemic control was not significant.

CONCLUSIONS

Periodontitis and functional dentition are significantly associated with fibre intake and glycaemic control in adults. Dietary intake, however, does not mediate the association between dental conditions and glycaemic control.

Oral and systemic health: is there a "new" link with COVID-19?

OBJECTIVES

The objective of the present narrative review was to evaluate the evidence of a possible association between periodontitis and COVID-19, and its biological plausibility, using as models the potential associations with cardiovascular diseases, diabetes, and some respiratory diseases.

METHODS

A recent systematic review was used as main reference to explore the associations of periodontitis with different respiratory diseases, including COVID-19, following two focussed questions: a PECOS question, aimed to explore epidemiological evidence, and a PICOS question, designed to explore the evidence derived from intervention studies. In addition to that evidence, other relevant scientific documents, including consensus papers, were carefully selected and appraised.

FINDINGS

Convincing evidence was found to support the association of periodontitis and cardiovascular diseases, diabetes, and some respiratory diseases. The biological plausibility behind those associations is based on four factors: (1) bacteraemia of oral bacteria and periodontal pathogens, (2) increased systemic inflammation, (3) common genetic factors, and (4) common environmental risk factors. Limited initial evidence is available to support an association between periodontitis and COVID-19 complications. Among the proposed factors to explain the suggested association, a combination of the previously mentioned factors, plus additional factors related with SARS-CoV-2 characteristics and pathogenicity, has been suggested.

CONCLUSIONS

Initial evidence suggests that periodontitis may be associated with a more severe COVID-19 and with a higher risk of death due to COVID-19.

CLINICAL RELEVANCE

Due to the possible association between periodontitis and an increased severity for COVID-19, additional efforts should be made to improve oral and periodontal health, including the promotion of oral healthy habits, such as oral hygiene.

Effects of advanced glycation end products (AGEs) on the differentiation potential of primary stem cells: a systematic review

The formation and accumulation of advanced glycation end products (AGEs) have been associated with aging and the development, or worsening, of many degenerative diseases, such as atherosclerosis, chronic kidney disease, and diabetes. AGEs can accumulate in a variety of cells and tissues, and organs in the body, which in turn induces oxidative stress and inflammatory responses and adversely affects human health. In addition, under abnormal pathological conditions, AGEs create conditions that are not conducive to stem cell differentiation. Moreover, an accumulation of AGEs can affect the differentiation of stem cells. This, in turn, leads to impaired tissue repair and further aggravation of diabetic complications. Therefore, this systematic review clearly outlines the effects of AGEs on cell differentiation of various types of primary isolated stem cells and summarizes the possible regulatory mechanisms and interventions. Our study is expected to reveal the mechanism of tissue damage caused by the diabetic microenvironment from a cellular and molecular point of view and provide new ideas for treating complications caused by diabetes.

Anti-inflammaging effects of vitamin D in human gingival fibroblasts with advanced glycation end product stimulation

Background/purpose

:Both periodontal disease and diabetes mellitus (DM) are long-term inflammatory disorders that are highly prevalent and have a significant health impact. Inflammaging, a state of pre-aging and hyperinflammatory state has been acknowledged for its role in DM patients to have heightened risk of periodontitis. Numerous evidences revealed that inflammaging contributed by cell senescence, acceleration of inflammation and oxidative stress participates in the destruction of periodontium in DM. Abilities of vitamin D in suppressing inflammation and oxidative stress have been revealed in a range of tissues, however in DM’s gingival cells, the effect remain undefined.

Materials and methods

: Under the stimulation of advanced glycation end-products (AGEs), we assessed the cell proliferation in human gingival fibroblast (HGF), IL-6 and IL-8 secretions, cellular senescence expression and generation of reactive oxygen species (ROS) with or without vitamin D intervention. Following that, we examined the expression of Nrf2 and HO-1 to see if vitamin D was able to modulate the anti-oxidant signaling. A knockdown experiment was then conducted to proof the participation of Nrf2 on the secretion of pro-inflammatory IL-6 and IL-8.

Results

: Following the treatment of vitamin D, AGEs-elicited IL-6 and IL-8 production and cell senescence were dose-dependently repressed. Moreover, vitamin D attenuated AGEs-induced ROS in a dose-dependent pattern. Results from qRT-PCR demonstrated vitamin D reversed the suppression of Nrf2 and HO-1 induced by AGEs. Our findings revealed that the anti-inflammatory and anti-oxidant effect in vitamin D was mediated via the upregulation of Nrf2 expression.

Conclusion

: These data showed that high levels of AGEs in the gingiva lead to inflammaging reflected by increased pro-inflammatory cytokines, cell senescence expression and oxidative stress. Vitamin D supplementation can reduce oxidative stress and inflammation via the upregulation of Nrf2 signaling and hence, may be a potential approach for treatment of diabetes-associated periodontitis.

Prevalence and Associated Factors for Periodontal Disease among Type I and II Diabetes Mellitus Patients: A Cross-Sectional Study

In Saudi Arabia, the prevalence of diabetes mellitus (DM) is high. DM is a risk factor for periodontal disease. The current study aimed to estimate the prevalence and potential associated factors for periodontitis among type I and II DM patients in Abha, Saudi Arabia. A cross-sectional study was conducted among patients with DM who attended the Periodontal Consultant Center at King Khalid University and Aseer Central Hospital, in Abha city, from January 2020 to January 2022. A questionnaire was used to collect relevant data. Patients were assessed for the severity of periodontitis. A total of 499 DM patients were enrolled in this study. The prevalence of periodontitis was 7.4% among type I DM and 46.4% among type II DM patients. The prevalence of periodontitis was significantly associated with age among type I DM patients (p-value = 0.001) and type II DM patients (p-value = 0.001), respectively, and smoking among type I DM patients (p-value = 0.002) and among type II DM patients (p-value = 0.000), respectively. Age and smoking were the potential associated factors for the prevalence of periodontitis among type I and II DM. The study provides evidence about the prevalence of periodontitis among DM patients, creates awareness regarding the factors that potentially contribute to worsening periodontal tissues, and the importance of early diagnosis and prevention to avoid the irreversible destruction of the periodontal tissues.

Oral Microbiota in Children and Adolescents with Type 1 Diabetes Mellitus: Novel Insights into the Pathogenesis of Dental and Periodontal Disease

The oral microbiota can be influenced by multiple factors, but only a few studies have focused on the role of glycemic control in determining early alterations of oral microbiota and their association with pathogenesis of both periodontitis and caries. The aim of this study is to evaluate the interplay between bacteria composition, oral hygiene, and glycemic control in a cohort of children with T1D. A total of 89 T1D children were enrolled (62% males, mean age: 12.6 ± 2.2 years). Physical and clinical characteristics, glucometabolic parameters, insulin treatment, and oral hygiene habits data were collected. Microbiological analysis was performed from saliva samples. A high prevalence of cariogenic and periodontopathogens bacteria in our cohort was detected. In particular, in all subjects Actinomyces spp., Aggregatibacter actinomycetemcomitans, Prevotella intermedia, and Lactobacillus spp. were isolated. S. mutans was found in about half of the analyzed sample (49.4%), in particular in patients with imbalance values of glycemic control. Moreover, a higher presence of both S. mutans and Veillonella spp. was detected in subjects with poorer glycemic control, in terms of HbA1c, %TIR and %TAR, even adjusting for age, sex, and hygiene habits as covariates. Virtuous oral hygiene habits, such as frequency of toothbrush changes and professional oral hygiene, negatively correlated with the simultaneous presence of Tannerella forsythia, Treponema denticola, and Porphyromonas gingivalis, red complex bacteria. Our study shows it is crucial to pay attention to glycemic control and regular oral hygiene to prevent the establishment of an oral microbiota predisposing to dental and periodontal pathology in subjects with T1D since childhood.

The oral microbiota and gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is one of the most frequent endocrine conditions during pregnancy. GDM is linked to adverse pregnancy outcomes and has implications for maternal health. Studies have demonstrated the link between pathogenic periodontal bacteria, glycemic control, and the risk of diabetes. The objective of the current study is to perform a mini-review of the available literature on the potential changes in the oral microbiota of women with GDM. The review was conducted by two independent reviewers (LLF and JDC). Indexed electronic databases (PubMed/Medline, Cochrane Library, Web of Science, and Scopus) were searched, including articles published in English and Portuguese. A manual search was also performed to identify related articles. The oral microbial community of pregnant women with GDM is unique from that of healthy pregnant women. The majority of the alterations found in the oral microbiota of women with GDM point to a pro-inflammatory environment with high levels of bacteria associated with periodontitis (Prevotella, Treponema, anaerobic bacteria) and a depletion of bacteria associated with periodontal health maintenance (Firmicutes, Streptococcus, Leptotrichia). More well-designed studies differentiating between pregnant women with good oral health and those with periodontitis are needed to ascertain which differences are due to GDM or periodontitis.

Impact of systemic health on treatment outcomes in endodontics

BACKGROUND

The healing of periapical lesions after root canal treatment (RCT) is not the result of the curative action of the treatment. The process of healing begins with inflammation, and is resolved by the clearance of the immunogen that induces the immune response. Then, the periapical tissue itself carries out the healing of the periapical lesion, by repair or by a combination of repair and regeneration, depending on the host's reparative response working properly. The ultimate objective of RCT is to achieve wound healing by removing the source of bacterial antigens and toxins, allowing chronic inflammatory tissue to become reparative tissue. Some systemic conditions increase the susceptibility of the host to infection or impair the tissue reparative response, maintaining the inflammatory process and periapical bone resorption after RCT. This can cause the failure of RCT and even the need for extraction of the affected tooth.

OBJECTIVE

To analyse the scientific literature on the possible influence of systemic conditions on the treatment outcomes in endodontics, as well as to discuss the biological mechanisms that may be involved.

METHODS

The search was carried out in PubMed, SCOPUS and EMBASE. The inclusion criteria established were original scientific articles reporting data about some systemic condition in relation to treatment outcomes in endodontics, including clinical studies and studies carried out in animal models.

RESULTS

Systemic factors (age, nutrition, stress, hormones, smoking habits), and systemic diseases, such as diabetes, cardiovascular diseases, osteoporosis, HIV infection, inflammatory bowel disease, and others, can influence or interfere in the repair of periapical tissues after RCT.

DISCUSSION

Some of these systemic diseases can alter bone turnover and fibroblast function, preventing or delaying periapical wound healing. Others can alter the microvasculature, reducing nutrients and oxygen supply to periapical tissues. As a result, these systemic conditions can decrease the success rate of RCT and provoke incomplete wound healing (typically granulomatous tissue formation) in the periapical region.

CONCLUSIONS

The results of this narrative review show worse success rate of RCT, with higher percentage of postoperative radiolucent periapical lesions and higher proportion of non-retained teeth (RFT), associated with several systemic conditions, such as smoking habits and diabetes.

The Bidirectional Relationship between Periodontal Disease and Diabetes Mellitus-A Review

Periodontitis is a chronic inflammatory disease caused by the presence of a bacterial biofilm known as dental plaque. This biofilm affects the supporting apparatus of the teeth, especially the periodontal ligaments and the bone surrounding the teeth. Periodontal disease and diabetes seem to be interrelated and in a bidirectional relationship, and have been increasingly studied in recent decades. For example, diabetes mellitus has a detrimental effect on periodontal disease, increasing its prevalence, extent, and severity. In turn, periodontitis negatively affects glycemic control and the course of diabetes. This review aims to present the most recently discovered factors that contribute to the pathogenesis, therapy, and prophylaxis of these two diseases. Specifically, the article focuses on microvascular complications, oral microbiota, pro- and anti-inflammatory factors in diabetes, and periodontal disease. As presented in this review, these two diseases require specific/ complementary therapeutic solutions when they occur in association, with new clinical trials and epidemiological research being necessary for better control of this interdependent pathogenic topic.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Evaluation of Lipid Peroxidation in the Saliva of Diabetes Mellitus Type 2 Patients with Periodontal Disease

As oxidative stress has been implicated in the pathogenesis of diabetes mellitus and periodontitis, it may serve as a link between these conditions. Therefore, as a part of the present study, salivary lipid peroxidation (LP) in periodontitis patients with and without diabetes mellitus type 2 (DM2) was evaluated, along with the periodontal therapy effectiveness. The study sample comprised of 71 DM2 patients with periodontitis and 31 systemically healthy controls suffering from periodontitis of comparable severity. In all participants, periodontal indices—plaque index (PI), gingival index (GI), papilla bleeding index (PBI), probing pocket depth (PPD), and clinical attachment level (CAL)—were recorded, and salivary LP was measured using a spectrophotometric method prior to treatment initiation and three months post-treatment. At baseline, mean salivary LP in DM2 patients was higher than that measured for the control group, but the difference did not reach statistical significance (p > 0.05), whereas a positive significant correlation was found between PPD and LP in both groups. Three months after nonsurgical periodontal therapy, clinical periodontal parameters and salivary LP levels were significantly reduced in both groups (p < 0.05). These findings indicate that the improvement in clinical periodontal status following nonsurgical periodontal therapy is accompanied by a significant decrease in salivary LP in DM2 patients, suggesting that periodontitis, rather than diabetes, is the primary driver of the elevated salivary LP in this group.

Analysis of subgingival micro-organisms based on multi-omics and Treg/Th17 balance in type 2 diabetes with/without periodontitis

Type 2 diabetes mellitus (T2DM) and periodontitis are common and interrelated diseases, resulting in altered host response microbiota. The subgingival micro-organisms play a key role in periodontitis pathogenesis. To assess the shift of subgingival microbiome and metabolome in T2DM, we performed an analysis of the subgingival microbiome in patients with T2DM (n = 20) compared with non-diabetes (ND) subjects (n = 21). Furthermore, patients were subdivided into 10 T2DM with periodontitis (DP), 10 T2DM without periodontitis (DNP), 10 periodontitis (P), and 11 healthy control (H) groups. 16SrRNA gene sequencing combined with ultra high-performance liquid chromatography-mass spectrometry (UHPLC-MS) based metabolomics was performed in all participants. T lymphocyte immunity was analyzed by flow cytometry. Furthermore, the network relationship among subgingival micro-organisms, metabolites, blood glucose level, and T lymphocyte immunity were analyzed. The results showed that the difference of the subgingival microbiome from healthy to periodontitis status was less prominent in T2DM compared with ND, though the clinical signs of disease were similar. The bacteria Eubacterium nodatum group, Filifactor, Fretibacterium, Peptostreptococcus, and Desulfovibrio, amongst others, may be important in the pathopoiesia of periodontitis in the T2DM state. In addition, some dominant bacteria showed network relationships. The Treg/Th17 ratio was lower in the DP and DNP groups than in the P and H groups-though that of P was lower than for H. The percentage of CD4+/CD8+ PD1 and CD8+ PDL1 was higher in the DP and DNP groups than in the H group; the percentage of CD8+ PDL1 was higher in the DP than P groups. Subgingival micro-organisms in periodontitis had a significant metabolic shift in terms of their signature metabolites. Butyrate metabolism and phenylalanine metabolism may play a role in the pathogenesis of periodontitis with/without T2DM. Specifically, biphenyl degradation, tryptophan metabolism, and the two-component system may play important roles in periodontitis with T2DM. Lastly, the network relationship among subgingival micro-organisms, metabolites, blood glucose level, and T lymphocyte immunity were unbalanced. This study identified the changes in the subgingival microbiome associated with periodontitis in T2DM, as well as the associated network between bacterial flora, metabolism dysbiosis, and immune regulation.

Expression of advanced glycation end products and receptors in gingival tissues of patients with noninsulin-dependent diabetes mellitus-associated periodontitis

Background/purpose

Advanced glycation end products (AGEs) are known to accumulate in the periodontal tissues of patients with diabetes mellitus (DM). Through this study, we aimed to investigate the distribution of AGEs and the receptor of AGEs (RAGE) in the gingival tissues of patients with chronic periodontitis with and without non-insulin-dependent diabetes mellitus (NIDDM).

Materials and methods

Gingival biopsy samples from 13 patients with both NIDDM and periodontitis and 6 patients with both non-DM (NDM) and periodontitis were collected. The tissue sections were processed using immunohistochemical (IHC) staining to detect the distributions of AGEs and RAGE. Spearman correlation coefficients of all samples were calculated (P < 0.05) for the AGE and RAGE rankings of the following clinical parameters: plaque score (PI), probing depth (PD), bleeding on probing (BOP), and tooth loss (TL).

Results

IHC analysis revealed that AGEs among patients with NIDDM had a significantly higher ranking than those of the NDM group (P < 0.05). Positive staining for RAGE was observed in both groups but was not significantly different (P > 0.05). A positive correlation between AGE ranking and TL was observed in the NIDDM group, but not between AGE ranking and PI, PD, or BOP. The distribution of RAGE was not correlated with PI, PD, BOP, or TL.

Conclusion

AGEs were particularly distributed in the highly inflamed gingiva of patients with NIDDM-associated periodontitis and was statistically correlated with the long-term parameter TL.

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.

Is Periodontitis a Risk Factor for Lung Cancer? A Meta-Analysis and Detailed Review of Mechanisms of Association

Background

Numerous studies have explored the correlation of periodontal disease (PD) with the risk of lung cancers, but the findings were inconsistent. Therefore, we did a meta-analysis to ascertain the correlation of PD with the risk of incident lung cancer.

Methods

The authors searched relevant studies in databases (PubMed, Web of Science, Scopus, Embase, and MEDLINE) till November 2020. We registered the study at the International database of Prospectively Registered Systemic Reviews under the CRD42020198119. The summary relative risk (RR) along with a 95% confidence interval (CI) was calculated using fixed-effects models.

Results

Twelve studies were included in the qualitative synthesis. The pooled analysis revealed that PD was significantly associated with an increased risk of lung cancer (RR 1.71; 95%CI 1.61-1.81; P < 0.01). Subgroup analysis was performed based on gender distribution, geographic location, and type of studies.

Conclusion

From this current evidence, PD is a potential risk factor for the development of lung cancer. The risk for incidence of lung cancer is surged twice in the patients with PD, even though age and smoking are controlled in the studies.

Effects of Nonsurgical Periodontal Therapy on Salivary 8-Hydroxy-Deoxyguanosine Levels and Glycemic Control in Diabetes Mellitus Type 2 Patients

Diabetes and periodontitis are complex chronic diseases that are potentially interrelated, as well as associated with oxidative stress. Thus, the aim of the present study was to evaluate the influence of nonsurgical periodontal treatment on salivary 8-hydroxy-deoxyguanosine (8-OHdG) levels and glycemic control in patients suffering from both diabetes mellitus type 2 (DM2) and periodontitis. The study sample included 53 DM2 patients, while 31 systemically healthy patients served as controls. Participants in both groups suffered from periodontitis of comparable severity. Periodontal clinical parameters, namely plaque index (PI), gingival index (GI), papilla bleeding index (PBI), probing pocket depth (PPD), and clinical attachment level (CAL) were recorded, along with salivary 8-OHdG levels and glycated hemoglobin (HbA1c). Levels of 8-OHdG were analyzed by ELISA. All aforementioned parameters were evaluated prior to commencing the study and at 90-day follow-up upon nonsurgical periodontal therapy completion. At baseline, salivary levels of 8-OHdG in DM2 patients were significantly higher (1.17 ng/mL) than those measured for the control group (0.75 ng/mL) and showed significant positive correlation with GI and PPD (p < 0.05). Three months after nonsurgical periodontal therapy, the salivary 8-OHdG levels were significantly reduced in DM2 patients (p < 0.05). Analysis results also revealed statistically significant changes in all measured clinical parameters between baseline and three-month follow-up in both groups (p < 0.05). Upon treatment completion, a decline in the HbA1c level was noted in DM group, but it did not reach statistical significance (p > 0.05). It can be concluded that DM2 patients benefit from non-surgical periodontal therapy, as indicated by a marked reduction in their salivary 8-OHdG level and a modest improvement in glycemic control. Short-term clinical benefits noted in the DM group were similar to those observed in the non-diabetic periodontal patients.

The Effect of Two Different Doses of Astaxanthin on Alveolar Bone Loss in an Experimental Model of Periodontitis in Diabetic Rats

This study evaluated the effects of astaxanthin (ASX) on alveolar bone loss, receptor activator of nuclear factor-κB ligand (RANKL), and osteoprotegerin (OPG) activity in ligature-induced periodontitis in diabetic rats. Diabetes mellitus (DM) was induced with 50 mg/kg intraperitoneal streptozotocin in 40 male Wistar rats. The Wistar rats were divided into six experimental groups: non-ligated (NL; n = 6); ligature only (L; n = 6); DM only (D; n = 6); DM + ligature (DP; n = 6); DM + ligature + 1 mg/kg/day ASX (ASX 1 group; n = 8); and DM + ligature + astaxanthin 5 mg/kg/day ASX (ASX 5 group; n = 8). Silk ligatures were placed along the gingival margin of the left mandibular first molar tooth. The study duration was 11 days, after which the animals were euthanised. Changes in alveolar bone levels were clinically measured, and RANKL and OPG activities were immunohistochemically examined. Alveolar bone loss was the most significant in the DP group (p < 0.05). Decreased alveolar bone loss was observed in the ASX 5 group (p < 0.05). Although RANKL activity was highest in the DP group, it was observed at lower levels in the groups to which ASX was administered. OPG activity did not differ between groups (p > 0.05). The results of this study suggested that 1 and 5 mg/kg ASX administration reduced RANKL activity and alveolar bone loss in rats with experimentally induced periodontitis.

Domiciliary Management of Periodontal Indexes and Glycosylated Hemoglobin (HbA1c) in Type 1 Diabetic Patients with Paraprobiotic-Based Toothpaste and Mousse: Randomized Clinical Trial

Background: Periodontal disease is a chronic inflammation of periodontal tissues. Several systemic diseases are related to this condition. One of the strongest associations is that of periodontitis and type 2 diabetes mellitus (T2DM). On the contrary, the link with type 1 diabetes mellitus (T1DM) has not been extensively investigated. The objective of the present report is to evaluate and compare the effect of two domiciliary oral hygiene protocols on the periodontal clinical status as well as on the metabolic control in patients affected by T1DM. Methods: Sample size calculation required 20 patients per group, therefore 40 patients were equally and randomly assigned to the following home oral care protocols: a probiotic-based one (trial group) and a natural extracts-based one (control group). At the beginning of the study, after 3 and 6 months, the following periodontal indexes were collected: Probing Pocket Depth (PPD), Plaque Index (PI), Clinical Attachment Level (CAL), Bleeding on Probing (BoP), and Glycosylated Hemoglobin (HbA1c). Data underwent statistical analysis (significance threshold: p < 0.05). Results: In both groups, significant decreases in the periodontal clinical indexes were found at various time frames, whereas the levels of HbA1c significantly decreased only in the control group. Conclusions: Both the domiciliary treatments administered can significantly improve PPD, PI, CAL, and BOP parameters, whereas only the natural extracts-based gel seems to decrease HbA1c levels of T1DM patients.

Impact of Periodontitis on Glycemic Control and Metabolic Status in Diabetes Patients: Current Knowledge on Early Disease Markers and Therapeutic Perspectives

Diabetes mellitus and periodontitis are two of the most common chronic diseases affecting the world's population, and they are intimately linked. For several years, in fact, it has been known that there is an interdependent relationship between the two diseases: Diabetes promotes the destruction of periodontal tissues, and periodontal disease negatively affects glycemic control. In relation to the control of dental plaque and oral dysbiosis responsible for periodontal disease, both nonsurgical and surgical therapy associated with proper home hygiene procedures have emerged as essential for good glycemic control. Moreover, several evidences suggest the essential role played by the control of periodontal disease in preventing the onset of the most common complications of diabetes: cardiovascular diseases, retinopathies, and other systemic diseases. The aim of this study is to update the current knowledge on the bi-univocal relationship between diabetes and periodontitis and the impact of therapy in the optimal management of these two disorders. From the information found in the literature, it has emerged that the correct treatment of periodontal disease in diabetic patients represents one of the main mechanisms and means currently established and valid to control periodontal disease and glucose metabolism and prevent the onset or development of diabetic complications.

Salivary Microbiome Profile of Diabetes and Periodontitis in a Chinese Population

Aim

There is a bidirectional association between diabetes and periodontitis. However, the effect of diabetes on the periodontitis salivary microbiota has not been elucidated. The aim of this study was to determine the effect of the presence of diabetes on the microbiota among Chinese patients with periodontitis.

Materials and Methods

Unstimulated whole saliva samples were collected from the periodontitis with diabetes group (TC), chronic periodontitis group (CP), and periodontally healthy and systemically healthy group (H) by spitting method. Bacterial genomic DNA was PCR-amplified at the V4 variable region of 16S rRNA gene. The library was constructed according to the obtained sequence results, and biological analysis and statistical analysis were carried out. Functional prediction of three groups of microbial communities was performed by the PICRUSt algorithm.

Results

There was no significant difference in bacterial diversity between the TC and CP groups. Compared with the H group, the TC group and CP group presented a higher diversity of salivary flora. Firmicutes, Streptococcus, Haemophilus, Veillonella, and Haemophilus parainfluenzae dominated the H group. Corynebacterium, Leptotrichia, Dialister, Comamonas, Capnocytophaga, Catonella, Filifactor, Campylobacter, Treponema, Campylobacter concisus, Prevotella oralis, and Porphyromonas gingivalis were significantly enriched in the TC and CP groups. Among them, Treponema and P. oralis were the most abundant in the TC group. The PICRUSt results showed that many pathways related to cell motility and functional metabolism of the salivary microbial flora changed in the TC group and the CP group.

Conclusions

Diabetes was not the main factor causing the altered diversity of salivary microbiota in patients with periodontitis; however, the presence of diabetes altered the abundance of some microbiota in saliva.

Presence of periodontitis may synergistically contribute to cancer progression via Treg and IL-6

A close causal relationship has been suggested to exist between cancer and periodontitis. We hypothesized that the immune surveillance system is impaired in patients with periodontitis, which contributes to cancer development and growth. Therefore, the present study investigated the relationship between immune surveillance mechanisms and periodontitis in cancer patients. The presence or absence of periodontitis was assessed and the peripheral blood (PB) concentrations of IL-6, immunosuppressive cytokines (VEGF, TGF-β1, and CCL22) and proportion of T regulatory cells (Treg, CD3 + CD4 + CD25 + Foxp3 +) were measured. Subjects were classified into the following four groups: non-cancer patients without periodontitis (C − P −), non-cancer patients with periodontitis (C − P +), cancer patients without periodontitis (C + P −), and cancer patients with periodontitis (C + P +). The results of a multivariate analysis showed that the PB concentration of IL-6 was significantly higher in C + than in C- and higher in C + P + than in C + P −. The PB proportion of Treg was significantly higher in C + P + than in C + P −, C − P + , and C − P −. The results of this study suggested that the presence of periodontitis and cancer synergistically increased Treg in PB, which may be one of the underlying causes of immunosuppression and immune evasion in cancer. It was also suggested that the presence of periodontal disease and/or cancer also increases IL-6 in PB, which would be associated with cancer progression. These results suggest the possibility that the presence of periodontitis might synergistically contribute to cancer progression.

Cross-Sectional Analysis of Oral Healthcare vs. General Healthcare Utilization in Five Low- and Middle-Income Countries

Oral health is integral to overall health and is often neglected, especially in low- and middle-income countries (LMICs). Oral disease, including untreated dental caries, affects nearly 3.5 billion people globally, contributing to poor health and quality of life. To examine the relationship between the utilization of general healthcare and oral healthcare, we conducted an exploratory cross-sectional study of first-visit interview data collected from a convenience sample of 3,422 low-income mothers and 4,324 children aged 6 months through 6 years participating in a community-based oral health and nutrition program in five LMICs (Ecuador, El Salvador, India, Nepal, and Vietnam) from 2006–2015. We used descriptive and exploratory association analysis to identify patterns of oral healthcare utilization for mothers and children compared to medical care utilization, specifically maternal prenatal care and child immunizations. Overall, 89.6% of the mothers had received prenatal care for at least one child, but only 76.4% had ever received dental care and 50% were currently suffering from oral health symptoms, primarily oral pain. Mothers who received prenatal care were significantly more likely to have accessed dental care compared to those who had not received prenatal care (OR = 2.62, 95% CI: 2.06, 3.32). Overall, 95.4% of the children had current immunizations, but only 30.1% had ever received dental care, and 32.4% were currently suffering from oral pain. Children whose immunizations were up-to-date were more likely to have received dental care, with a significant association in Ecuador (OR = 3.29, 95% CI: 2.06, 5.30). Compared to utilization of general healthcare, oral healthcare was under-utilized by mothers and children in our sample from five LMICs. Integration of prevention- and treatment-oriented oral healthcare into primary medical care services, particularly prenatal care and child immunizations, could help increase access to oral healthcare and improve women's and children's oral health.

Managing the Systemic Impact of Periodontitis

Periodontitis is a microbially driven host-mediated disease that leads to loss of periodontal attachment and bone. It is associated with elevation of systemic inflammatory markers and with the presence of systemic co-morbidities. Furthermore, periodontal treatment leads to a 24-48 h-long acute local and systemic inflammatory response. This systemic response might increase the burden of patients with compromised medical history and/or uncontrolled systemic diseases. The correlation between periodontitis and systemic diseases, the impact of periodontitis on the quality of life and public health, the effects of periodontal treatment on systemic health and disease, and the available methods to manage systemic inflammation after periodontal therapy are discussed. The main focus then shifts to a description of the existing evidence regarding the impact of periodontitis and periodontal treatment on systemic health and to the identification of approaches aiming to reduce the effect of periodontitis on systemic inflammation.

Astaxanthin Enhances Gingival Wound Healing following High Glucose-Induced Oxidative Stress

Fibroblasts of the gingiva play a key role in oral wound healing in diabetes. In this study, effects of astaxanthin (ASTX), a xanthophyll carotenoid, were tested on gingival fibroblasts in a wound healing assay in vitro. The aim of this study was to determine whether ASTX can recover delayed wound healing or not when oxidative stress is elevated by high glucose exposure. For this purpose, human gingival fibroblasts were incubated with or without ASTX following exposure to systemic doses of low glucose (LG) and high glucose (HG) in culture media (5- and 25-, 50 mM D-glucose in DMEM Ham's F12) following 24 hours of incubation. Levels of ROS (Reactive oxygen species) were determined for each experimental group by confocal microscopy. Cell proliferation and viability were assessed by an automated cell counter with trypan blue assay. Wound healing assay was designed in 60 mm petri dishes. Cells were exposed to 5-, 25-, and 50 mM glucose for 24 hours, and a straight line free of cells was created upon full confluency. 100 μM ASTX was added to the recovery group, simultaneously. Cells were monitored with JuLI^Ⓡ-Br Cell History Recorder. ROS levels were significantly increased with increasing glucose levels, while cell proliferation and viability demonstrated a negative correlation with increasing oxidative stress. ROS levels significantly decreased in the 100 μM ASTX-treated group compared to the gingival fibroblasts treated with 50 mM HG medium-only, as well as growth rate and viability. Wound healing was delayed in a dose-dependent manner following high glucose exposure, while ASTX treatment recovered wounded area by 1.16-fold in the 50 mM HG group. Our results demonstrated that ASTX enhances gingival wound healing through its antioxidative properties following high glucose induced oxidative stress. Therefore, ASTX can be suggested as a promising candidate to maintain oral health in chronic wounds of the oral tissues related to diabetes.

The Complex Interrelationship between Diabetes Mellitus, Oral Diseases and General Health

There is emerging evidence that several oral diseases and conditions can be associated with DM. Dental caries, hyposalivation, fungal diseases and endodontics lesions may represent potential oral complications that can be aggravated by chronic hyperglycemia. Individuals with DM have a low perception of oral diseases which can lead to clinically important oral and systemic complications. This review aims to provide data on the most common oral signs and symptoms related to DM and to explore the mechanisms that might explain associations between DM and oral diseases in order to clarify the risks posed by poor oral health in DM. Since the linkage between oral diseases and DM is part of multifactorial aspects related to chronic hyperglycemic status and several common conditions affecting the whole body, both require rigorous self-control from patients and attention from medical and dental professionals.

Subgingival microbiome in periodontitis and type 2 diabetes mellitus: an exploratory study using metagenomic sequencing

Purpose

To explore differences in the subgingival microbiome according to the presence of periodontitis and/or type 2 diabetes mellitus (T2D), a metagenomic sequencing analysis of the subgingival microbiome was performed.

Methods

Twelve participants were divided into 4 groups based on their health conditions (periodontitis, T2D, T2D complicated with periodontitis, and generally healthy). Subgingival plaque was collected for metagenomic sequencing, and gingival crevicular fluids were collected to analyze the concentrations of short-chain fatty acids.

Results

The shifts in the subgingival flora from the healthy to periodontitis states were less prominent in T2D subjects than in subjects without T2D. The pentose and glucuronate interconversion, fructose and mannose metabolism, and galactose metabolism pathways were enriched in the periodontitis state, while the phosphotransferase system, lipopolysaccharide (LPS) and peptidoglycan biosynthesis, bacterial secretion system, sulfur metabolism, and glycolysis pathways were enriched in the T2D state. Multiple genes whose expression was upregulated from the red and orange complex bacterial genomes were associated with bacterial biofilm formation and pathogenicity. The concentrations of propionic acid and butyric acid were significantly higher in subjects with periodontitis, with or without T2D, than in healthy subjects.

Conclusions

T2D patients are more susceptible to the presence of periodontal pathogens and have a higher risk of developing periodontitis. The pentose and glucuronate interconversion, fructose and mannose metabolism, galactose metabolism, and glycolysis pathways may represent the potential microbial functional association between periodontitis and T2D, and butyric acid may play an important role in the interaction between these 2 diseases. The enrichment of the LPS and peptidoglycan biosynthesis, bacterial secretion system, and sulfur metabolism pathways may cause T2D patients to be more susceptible to periodontitis.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

Astaxanthin Inhibits Diabetes-Triggered Periodontal Destruction, Ameliorates Oxidative Complications in STZ-Injected Mice, and Recovers Nrf2-Dependent Antioxidant System

Numerous studies highlight that astaxanthin (ASTX) ameliorates hyperglycemic condition and hyperglycemia-associated chronic complications. While periodontitis and periodontic tissue degradation are also triggered under chronic hyperglycemia, the roles of ASTX on diabetes-associated periodontal destruction and the related mechanisms therein are not yet fully understood. Here, we explored the impacts of supplemental ASTX on periodontal destruction and systemic complications in type I diabetic mice. To induce diabetes, C57BL/6 mice received a single intraperitoneal injection of streptozotocin (STZ; 150 mg/kg), and the hyperglycemic mice were orally administered with ASTX (12.5 mg/kg) (STZ+ASTX group) or vehicle only (STZ group) daily for 60 days. Supplemental ASTX did not improve hyperglycemic condition, but ameliorated excessive water and feed consumptions and lethality in STZ-induced diabetic mice. Compared with the non-diabetic and STZ+ASTX groups, the STZ group exhibited severe periodontal destruction. Oral gavage with ASTX inhibited osteoclastic formation and the expression of receptor activator of nuclear factor (NF)-κB ligand, 8-OHdG, γ-H2AX, cyclooxygenase 2, and interleukin-1β in the periodontium of STZ-injected mice. Supplemental ASTX not only increased the levels of nuclear factor erythroid 2-related factor 2 (Nrf2) and osteogenic transcription factors in the periodontium, but also recovered circulating lymphocytes and endogenous antioxidant enzyme activity in the blood of STZ-injected mice. Furthermore, the addition of ASTX blocked advanced glycation end products-induced oxidative stress and growth inhibition in human-derived periodontal ligament cells by upregulating the Nrf2 pathway. Together, our results suggest that ASTX does not directly improve hyperglycemia, but ameliorates hyperglycemia-triggered periodontal destruction and oxidative systemic complications in type I diabetes.

Glucose variability and periodontal disease in type 1 diabetes: a cross-sectional study-The "PAROdontopatia e DIAbete" (PARODIA) project

AIMS

Periodontal disease (PD) is a chronic inflammation of periodontal tissue associated with infection from specific anaerobic pathogens contained in dental plaque. Both type 1 and type 2 diabetes are associated with an increased prevalence of PDs. A two-way relationship between diabetes and periodontitis has been proposed, with diabetes increasing the risk for periodontitis, and periodontal inflammation negatively affecting glycaemic control. To date, the relationship between PD and glucose variability in type 1 diabetes has not been evaluated. To investigate the prevalence of PD in patients with type 1 diabetes and its association with glycemic control and glucose variability.

METHODS

In this cross-sectional study, all enrolled patients were scheduled to attend both a diabetologic and a periodontal visit. HbA1c, glucose coefficient of variation (CV), loss of clinical attachment (CAL), and periodontal probing depth (PPD) were collected.

RESULTS

136 patients were included in the analysis. The prevalence of PD was 63%. A significant correlation was found between mean CAL and glucose CV (r = 0.31, p = 0.002), but not with HbA1c. Mean PPD was also associated with glucose CV (r = 0.27 and 0.044), but not with HbA1c. In a multiple linear regression model, with mean CAL as dependent variable, age, glucose CV, and smoking habit resulted significantly associated (r = 0.23, p = 0.013; r = 0.33, p = 0.001; r = 0.34, p < 0.001, respectively). Assuming mean PPD as dependent variable, multiple linear regression analysis showed a significant association with glucose CV and smoking habits only.

CONCLUSIONS

PD is associated with glucose variability in patients with type 1 diabetes also after adjusting for the main confounders.

Advanced glycosylation end products inhibit the proliferation of bone-marrow stromal cells through activating MAPK pathway

BACKGROUND

The purpose of present study was to explore the mechanism of nuclear factor-kappa B (NF-κB), phosphatidylinositol 3-kinase (PI3K)/protein kinase B(PKB/Akt) and mitogen-activated protein kinase (MAPK) signaling pathways after intervention of advanced glycosylation end products (AGEs) on rat bone-marrow stromal cells (BMSCs).

METHODS

Prepare and identify AGEs. BMSCs were isolated from 16 SD rats and cultured with different concentration of AGEs. Cell viability was detected by cell counting kit-8 (CCK-8). BMSCs were cultured with AGEs (0.25 mg/ml) for 30 min, 12 h, 24 h, 72 h and 120 h. In addition, BMSCs were cultured with AGEs, AGEs + JNK inhibitor and AGEs + P38 inhibitor for 24 h and 48 h, respectively. Western blotting and RT-PCR were used to determine the protein and mRNA expression levels, respectively.

RESULTS

Cell viability of BMSCs was significantly correlated with concentration and effect time of AGEs (P < 0.05), and the most appropriate concentration was 0.25 mg/ml. AGEs stimulation significantly increased the protein expression levels of NF-κB p65, JNK, p38 (P < 0.05), decreased IκB (P < 0.05), but had no effect on the protein expression of Akt in BMSCs (P > 0.05). At the mRNA level, JNK and p38 inhibitors significantly reduced the levels of NF-κB p65, p38 and JNK, increased IκB (P > 0.05), but had no effect on Akt in BMSCs (P > 0.05). At the protein level, JNK and p38 inhibitors notably decreased the expression of NF-κB p65, p38, p-JNK, P-IκB and JNK (P < 0.001), and increased IκB (P < 0.05).

CONCLUSION

Advanced glycosylation end products can inhibit the proliferation of bone-marrow stromal cells through activating MAPK pathway.

Clindamycin as an Alternative Option in Optimizing Periodontal Therapy

Periodontal disease is an oral infectious and inflammatory disease caused by microorganisms that determine the host-mediated destruction of soft and hard periodontal tissues, which ultimately leads to tooth loss. Periodontitis affects a large part of the population, with various degrees of severity. Treatment consists of etiologic therapy: the removal of biofilm through mechanical debridement plus microbial elimination by supplementary measures. Antibiotic administration, either systemically or through local delivery, has been shown to improve clinical outcomes after mechanical periodontal treatment. Clindamycin is a lincosamide with a broad spectrum, being active against aerobic, anaerobic, and β-lactamase-producing bacteria. This antibiotic offers several advantages and some disadvantages and has been used in periodontal treatment both systemically and locally with various degrees of success. Among the properties that recommend it for periodontal treatment is the bacteriostatic effect, the inhibition of bacterial proteins synthesis, the enhancement of neutrophil chemotaxis, phagocytosis and the oxidative burst–oxidative stress storm. Furthermore, it is easily absorbed at the level of oral tissues in a considerable amount. This substantial tissue penetration, especially inside the bone, is synergistic with a stimulating effect on the host immune system. The aim of this review is to explore the applicability of this antibiotic agent and to evaluate its antimicrobial potential and limitations at the level of the oral biofilm associated with periodontal disease.

A clinical nomogram incorporating salivary Desulfovibrio desulfuricans level and oral hygiene index for predicting colorectal cancer

Background

Emerging evidence demonstrates that the salivary microbiome could serve as a biomarker for various diseases. To date, the oral microbiome’s role in the diagnosis of colorectal cancer (CRC) has not been fully elucidated. We aimed to illustrate the salivary microbiome’s role in diagnosing and predicting the risk of CRC.

Methods

We collected preoperational saliva from 237 patients [95 healthy controls (HCs) and 142 CRC patients] who underwent surgical resections or colorectal endoscopy in Renji Hospital from January 2018 to January 2020. Clinical demographics, comorbidities, and oral health conditions were obtained from medical records or questionnaires. Salivary microbial biomarkers were detected using quantitative polymerase chain reaction (qPCR) after DNA extraction. Multivariate logistic regression analysis was employed to analyze the risk factors for CRC. A predictive model for the risk of developing CRC was constructed based on logistic regression analysis. Predictive accuracy was internally validated by bootstrap resampling. A clinical nomogram was constructed to visualize the predictive model.

Results

Logistic regression analysis demonstrated that the risk factors associated with CRC included age at diagnosis, male sex, poor oral hygiene, and relative salivary Desulfovibrio desulfuricans abundance. The predictive model had good discriminative (0.866) and calibration abilities (0.834) after bias correction.

Conclusions

The model based on age, sex, oral hygiene index (OHI), and the salivary Desulfovibrio desulfuricans level, which is visualized by a clinical nomogram, can predict the risk of CRC. Developing good oral hygiene habits might reduce the risk of CRC.

Early markers of periodontal disease and altered oral microbiota are associated with glycemic control in children with type 1 diabetes

OBJECTIVES

To determine the relationship between periodontal disease and glycemic control in children with type 1 diabetes and to characterize the diversity and composition of their oral microbiota.

METHODS

Cross-sectional study including children with type 1 diabetes recruited from clinics at the Women's and Children's Hospital (Australia). Participants had a comprehensive dental assessment, periodontal examination, and buccal and gingival samples collected for 16S rRNA sequencing.

RESULTS

Seventy-seven participants (age 13.3 ± 2.6 years, 38 males, BMI z-score 0.81 ± 0.75) had a diabetes duration of 5.6 ± 3.9 years and median HbA1c of 8.5% (range 5.8-13.3), 69.4 mmol/mol (range 39.9-121.9). Thirty-eight (49%) had early markers of periodontal disease. HbA1c was positively correlated with plaque index (Rho = 0.34, P = 0.002), gingival index (Rho = 0.30, P = 0.009), bleeding on probing (Rho = 0.44, P = 0.0001) and periodontal pocket depth >3 mm (Rho = 0.21, P = 0.06). A 1% increase in HbA1c was independently associated with an average increase in bleeding on probing of 25% (P = 0.002) and with an increase in the rate of sites with pocket depth >3 mm of 54% (P = 0.003). Higher HbA1c was independently related to increased phylogenetic alpha diversity (P = 0.008) and increased compositional variation (beta diversity P = 0.02) in gingival, but not buccal, microbiota. Brushing frequency, plaque index, and gingival index had a significant effect on microbiota composition, independent of HbA1c.

CONCLUSIONS

Children with type 1 diabetes showed a continuous relationship between less favorable glycemic control and increased early markers of periodontal disease. Glycemic control was also related to the complexity and richness of the plaque microbiota, with diversity increasing as HbA1c levels increase.

Inflammatory Status and Glycemic Control Level of Patients with Type 2 Diabetes and Periodontitis: A Randomized Clinical Trial

Background: Based on the holistic approach to prevention diabetic disease, the role of periodontal inflammation in type 2 diabetes mellitus (T2DM) is under intensive scrutiny. Data from clinical trials have shown benefit from a periodontal therapy in providing patients with type 2 diabetes improvement despite relatively disappointing long-terms response rates. The aim of this study was to investigate the short-term glycemic control level and systemic inflammatory status after periodontal therapy. Methods: This was a randomized trial with a 6-months follow-up. Participants aged 56.4 ± 7.9 years with diagnosed type 2 diabetes and periodontitis were enrolled. Among the 187 type 2 diabetic patients, 93 were randomly assigned to receive non-surgical periodontal treatment immediately and 94 to receive the delayed treatment. Within and between groups comparison was done during the study period, and the differences between groups were assessed. Results: The difference between HbA1c values at baseline (Mdn = 7.7) and 6 months after non-surgical periodontal treatment (Mdn = 7.2) was statistically significant, U = 3174.5, p = 0.012, r = 0.187. However, although technically a positive correlation, the relationship between the glycated hemoglobin value and periodontal variables was weak. The differences between both the groups over 6 months were not statistically considerable, failing to reach statistical significance. At 6 months the difference between groups about the C-reactive protein (CRP) levels was statistically significant, U=1839.5, p = 0, r = 0.472, with a lower concentration for the intervention group. Furthermore, the intervention group showed a statistically significant difference between baseline and 6 months evaluation (U = 2606.5, p = 0, r = 0.308). Conclusions: The periodontal intervention potentially may allow individuals with type 2 diabetes to improve glycemic control and CRP concentrations, and diabetes alters the periodontal status.

A pilot study of red complex and three genera subgingival microbiome in periodontitis subjects with and without diabetes, evaluated by MinION platform

Background: Subgingival niche is one biofilm habitat containing rich microbiota, which plays an active role in maintaining the health of periodontal tissue and determining host response. As such, a study of changing subgingival biofilms is important for understanding the effect of a systemic condition. In this study, we compared the occurrence of six bacteria cohabiting in the subgingival area of periodontitis subjects, with (DP, n = 8) and without (NDP, n = 4) diabetes.

Methods: The six genus and species of targeted bacteria were confirmed by 16S rRNA amplicon sequencing on MinION nanopore platform. Descriptive statistic was used to describe the obtained data.

Results: We found that the six genus and species of targeted bacteria were detected but in different quantities in either group's periodontal pocket. Our data showed that Tannerella forsythia was the most abundant species in subgingival biofilms of the DP group of the red complex bacteria. In contrast, Aggregatibacter sp., which belongs to the phylum of proteobacteria, was present at a relatively lower level. In contrast, Fusobacterium sp., which belongs to orange complex bacteria, showed relative similarities in subgingival biofilms of both groups tested, while Veillonella sp., were abundant in the DP groups. 

Conclusions: Our data show that the diversity of classic periodontopathogens increased in the subgingival niche of periodontitis subjects with diabetes. It is the first study in Indonesia to apply MinION-based, full-length 16S rRNA amplicon sequencing in periodontitis patients with and without diabetes.

Evaluation of Cognitive Impairment in Type 2 Diabetic Patients with Chronic Periodontitis: A Cross-sectional Study

Background

Type 2 diabetes mellitus is an important risk factor for dementia; it also shares a bidirectional relationship with periodontitis. It is hypothesized that the increased severity of periodontitis is associated with cognitive decline in patients having uncontrolled diabetes mellitus. An added risk for future development as well as progression of dementia may be prophesied in such a scenario. Therefore, the present study was conducted to find a correlation between the cognitive impairment (CI) and periodontitis in type 2 diabetes mellitus patients.

Materials and Methods

A total of 160 older adults aged ≥60 years in Mangalore, Karnataka, India, were included in the present analysis. Known T2DM patients aged ≥60 years and diagnosed with periodontitis with a minimum clinical attachment loss (CAL) of ≥2 mm were considered in the present study. Montreal cognitive assessment test assessed the CI. The analysis was carried out using the χ² test, an independent t-test. Binary logistic regression analysis (enter method) was performed to derive the odds ratios (95% confidence interval).

Results

The study included 160 participants, out of which 120 had CI and 40 did not have CI. A statistically significant association was observed between moderate-to-severe periodontitis, HbA1c levels ≥7%, and CI after excluding the confounding factors like age, gender, diet, lifestyle habits, and education.

Conclusion

In the present study, cognitive impairment was found to coexist with HbA1c levels ≥7% and moderate-to-severe periodontitis in the elderly diabetics. The clinical implication of these findings adds opportunities to form disease modifiable areas in the elderly diabetic population at a risk for the development of dementia. Additionally, the impact of pre-existing CI on progression of periodontitis and vice versa has been discussed.

Oxidative stress links periodontal inflammation and renal function

Aims

Patients with chronic kidney disease (CKD) are also susceptible to periodontitis. The causal link between periodontitis and CKD may be mediated via systemic inflammation/oxidative stress. Using structural equation modelling (SEM), this cross‐sectional study aimed to explore the causal relationship between periodontal inflammation (PI) and renal function.

Materials and methods

Baseline data on 770 patients with stage 3–5 (pre‐dialysis) CKD from an ongoing cohort study were used. Detailed, bioclinical data on PI and renal function, as well as potential confounders and mediators of the relationship between the two, were collected. SEMs of increasing complexity were created to test the causal assumption that PI affects renal function and vice versa.

Results

Structural equation modelling confirmed the assumption that PI and renal function are causally linked, mediated by systemic oxidative stress. The magnitude of this effect was such that a 10% increase in PI resulted in a 3.0% decrease in renal function and a 10% decrease in renal function resulted in a 25% increase in PI.

Conclusions

Periodontal inflammation represents an occult source of oxidative stress in patients with CKD. Further clinical studies are needed to confirm whether periodontal therapy, as a non‐pharmacological approach to reducing systemic inflammatory/oxidative stress burden, can improve outcomes in CKD.