The effects of non-surgical periodontal therapy on glycemic control in diabetic patients: A randomized controlled trial

The Efficacy of Topical or Systemic Antibiotics as Adjuvants to Non-Surgical Periodontal Treatment in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Periodontitis and diabetes mellitus (DM) exhibit a bidirectional relationship and are globally significant systemic chronic conditions. The utilization of antibiotics alongside non-surgical periodontal treatment (NSPT) has been a subject of investigation in numerous clinical studies involving human subjects. Thus, the objective of this systematic review is to address the following question: "What is the efficacy of scaling and root planing (SRP) associated with antimicrobials in patients with type 2 DM and periodontitis?". Methods: A systematic review of the literature was conducted encompassing databases such as MEDLINE/PubMed, Scopus, and Web of Science up to July 2024. Additionally, alerts were configured to capture studies published from the initial search until manuscript submission. Randomized clinical trials assessing clinical periodontal parameters in DM patients undergoing SRP and receiving either topical or systemic antibiotics were compared against a control group (SRP only). Two investigators independently screened articles, extracted data, and evaluated their quality. The selection process, study characteristics, risk of bias, impact of antibiotics on clinical parameters, and certainty of evidence were elucidated in both textual and tabular formats. Meta-analysis was performed separately with forest plots generated for treatment modalities, period of evaluation, and type of antibiotics used. Results: Following the analysis of abstracts and full articles, a total of 30 randomized clinical trials were incorporated into this review, comprising 9 studies on the association of topical antibiotics and 21 studies on systemic antibiotic administration. The principal periodontal parameters assessed included probing pocket depth (PPD), clinical attachment level (CAL), plaque index (PI), and bleeding on probing (BoP). Conclusions: Analysis of the results led to the conclusion that adjunctive periodontal treatment with either topical or systemic antibiotics confers subtle clinical benefits. Nevertheless, owing to the heightened emergence of resistant bacteria and potential side effects, the use of antibiotic therapy in periodontal treatment should be judiciously administered.

Effects of diabetes mellitus on dental pulp: A systematic review of in vivo and in vitro studies

OBJECTIVES

This systematic review (PROSPERO CRD42021227711) evaluated the influence of diabetes mellitus (DM) on the response of the pulp tissue and in the pulp cells behaviour.

MATERIALS AND METHODS

Searches in PubMed/MEDLINE, Embase, Web of Science and OpenGrey were performed until March 2022. Studies evaluating the effects of DM in the pulp tissue inflammation and in the cell behaviour were included, followed by risk of bias assessment (Methodological Index for Non-Randomized Studies and SYRCLE's RoB tools). The meta-analysis was unfeasible, and a narrative synthesis for each outcome was provided.

RESULTS

Of the 615 studies, 21 were eligible, mainly with in vivo analysis (16 studies). The pulp inflammation (10 studies) was analysed mainly by haematoxylin-eosin stain; DM increased pulp inflammation/degeneration in 9 studies, especially after dental procedures. The cell viability (5 studies) was analysed mostly using MTT assay; DM and glycating agents decreased cellular viability in 3 studies. DM reduced collagen in all of three studies. There were controversial results regarding mineralization; however, increased alkaline phosphatase was reported in three of four studies.

CONCLUSIONS

DM seems to increase inflammation/degeneration and mineralization in the pulp tissue while reducing cell proliferation. Further analyses in human pulp are important to provide stronger evidence.

Systemic antibiotics adjuvants to scaling and root planing in type 2 diabetic and periodontitis individuals: Systematic review with network meta-analysis

Targeting inflammatory pathways is considered a common strategy to control type 2 diabetes (T2D) and periodontitis. This overview was to validate systemic antibiotics as an adjuvant to scaling and root planing (SRP) for the treatments of periodontal patients with T2D. Literature searches were conducted using Web of Science, PubMed, Cochrane, and EMBASE. Randomized trials comparing SRP and systemic antibiotics on glycated hemoglobin (HbA1c) and probing pocket depth (PPD) in adults with T2D and periodontitis were analyzed using network meta-analysis and meta-regression. At 3-month postintervention, meta-analyses of 16 studies revealed that SRP and SRP plus systemic antibiotics (SRPa) had similar significant effects in reducing HbA1c levels of - 0.72% and - 0.96% respectively. While SRP and SRPa also, respectively, reduced PPD of - 0.67 and - 0.89 mm, SRPa showed a better reduction than SRP. At 6-month postintervention, meta-analyses of 7 trials revealed that only SRP was effective in reducing HbA1c levels (-0.29%) but not SRPa. Although both SRP and SRPa still significantly reduced PPD by - 0.56 and - 0.81 mm, respectively, there was no difference between them. The current overview suggested that routine SRP alone is highly recommended for patients with T2D and periodontitis, since systemic antibiotics as an adjuvant provide a rather short-term effect.

Knowledge of bidirectional relationship between diabetes and periodontal disease among diabetes patients: A systematic review

INTRODUCTION

The bidirectional relationship between diabetes mellitus and periodontal disease has been reported in the literature, suggesting that poor glycemic control is strongly associated with increased risk of developing periodontal disease. Therefore, this systematic review evaluated the level of knowledge of this bidirectional relationship among patients with diabetes.

METHODS

This systematic review (protocol CRD42018117902) was conducted according to PRISMA guidelines. The following databases were considered: Medline/PubMed, Scopus, and Web of Science. Search strategy (April 05^th , 2021) considered proper combination of keywords and eligibility criteria. The quality of studies was evaluated using the Appraisal tool for Cross-Sectional Studies (AXIS).

RESULTS

Among the 328 records identified in the initial search, 24 studies were selected, considering a total of 8,693 patients. All studies used a cross-sectional design. Among the included studies, only five showed prevalence of knowledge higher than 50%, ranging from 5.8% to 75.9%. Interestingly, 58.0% of patients reported that they brush their teeth at least 1x/day, but only four studies reported that the dentist was the main source of information. In terms of methodology and result quality, just one study clearly showed all information evaluated by the AXIS tool. Most of studies did not report sample size calculations and did not used validated questionnaires to assess patient knowledge.

CONCLUSION

The results show that less than half of people with diabetes have knowledge about their increased risk for periodontal disease, and often the dentist is not the main source of information to motivate them.

The application of mesoporous silica nanoparticles as a drug delivery vehicle in oral disease treatment

Mesoporous silica nanoparticles (MSNs) hold promise as safer and more effective medication delivery vehicles for treating oral disorders. As the drug's delivery system, MSNs adapt to effectively combine with a variety of medications to get over systemic toxicity and low solubility issues. MSNs, which operate as a common nanoplatform for the co-delivery of several compounds, increase therapy effectiveness and show promise in the fight against antibiotic resistance. MSNs offer a noninvasive and biocompatible platform for delivery that produces long-acting release by responding to minute stimuli in the cellular environmen. MSN-based drug delivery systems for the treatment of periodontitis, cancer, dentin hypersensitivity, and dental cavities have recently been developed as a result of recent unparalleled advancements. The applications of MSNs to be embellished by oral therapeutic agents in stomatology are discussed in this paper.

Efficacy of Systemic Amoxicillin–Metronidazole in Periodontitis Patients with Diabetes Mellitus: A Systematic Review of Randomized Clinical Trials

Systemic amoxicillin–metronidazole was proven to be effective in managing periodontitis in systemically healthy patients. It was demonstrated that systemic antibiotic therapy can effectively improve clinical periodontal parameters and reduce periodontopathogenic organisms in the subgingival biofilm. However, the evidence for prescribing this drug combination to patients with diabetes remains insufficient. This systematic review was designed to evaluate the effectiveness of a systemic amoxicillin–metronidazole combination as an adjunct to nonsurgical periodontal therapy in patients with diabetes presenting with chronic periodontitis. The PubMed, Scopus, and Web of Science databases were electronically searched for randomized clinical trials in January 2022. Randomized clinical trials evaluating systemic amoxicillin–metronidazole therapy as an adjunct to nonsurgical periodontal therapy in patients with type 2 diabetes presenting with periodontitis were selected for screening. The qualities of the studies were assessed using the Cochrane Collaboration’s Tool for Assessing Risk of Bias Version 2.0 (ROB-2), and a GRADE assessment was applied to estimate the overall certainty of the evidence. Using predefined eligibility criteria, four clinical trials examining 209 patients were selected from the 611 articles identified in the search. Two studies reported a better reduction in clinical parameters when SRP was combined with systemic amoxicillin–metronidazole. Systemic amoxicillin–metronidazole was found to be as effective as clindamycin. Surgical therapy with systemic amoxicillin–metronidazole was more effective than nonsurgical therapy with systemic amoxicillin–metronidazole, even though both resulted in reduced clinical parameters. Combined amoxicillin–metronidazole was observed to reduce periodontal probing depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP) compared to no treatment or NSPT alone. However, the effect was not greater when compared to NSPT with clindamycin or surgical therapy with amoxicillin–metronidazole. Further randomized trials are required before clinical guidelines can be established for the use of systemic amoxicillin–metronidazole. Future randomized controlled clinical trials with long-term follow-ups are required to assess the efficacy of systemic antibiotic therapy in managing periodontitis in patients with diabetes.

Association of Diet-Related Systemic Inflammation with Periodontitis and Tooth Loss: The Interaction Effect of Diabetes

Diet is an important factor that can affect inflammatory processes. Diet-related systemic inflammation is closely linked to periodontitis and tooth loss. However, the role that systemic conditions play in influencing this association remains unclear. A cross-sectional analysis was conducted using the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014. Diet-related systemic inflammation was assessed by the Dietary Inflammatory Index (DII). Multivariate Cox regression models were used to investigate the association between DII and periodontal results, including total periodontitis, tooth loss, severe tooth loss, and the number of teeth lost. The interaction effects between DII and established covariates were tested. Higher DII scores, corresponding to a higher pro-inflammatory potential of the diet, were associated with an increased risk of periodontitis and tooth loss among the 10,096 eligible participants. There was an interaction between diabetes and DII on total periodontitis (p = 0.0136). No significant interaction effect was detected between DII and other established covariates. Participants who consumed an anti-inflammatory diet, and did not have diabetes, experienced the lowest risks of periodontitis and tooth loss. However, in the context of diabetes, the efficacy of such a diet may be weakened or even eliminated. Dietary interventions to manage oral health problems may need to take the individual's metabolic condition into account.

Periodontal disease and systemic health: An update for medical practitioners

INTRODUCTION

Chronic periodontal disease is a highly prevalent dental condition affecting tooth-supporting tissues. Scientific evidence is accumulating on links between periodontal disease and various systemic conditions. This narrative review provides a holistic yet succinct overview that would assist medical practitioners to deliver integrated care for better clinical outcomes.

METHOD

Scientific evidence on associations between periodontal disease and systemic conditions was synthesised and critically appraised. Key findings of latest prospective cohort studies, randomised clinical trials, and meta-analysis were closely assessed and compiled.

RESULTS

A bidirectional relationship has been established, indicating that diabetes and periodontal disease are closely linked and amplify one another, if not successfully controlled. Existing evidence also supports the associations of periodontal disease with cardiovascular diseases and adverse pregnancy outcomes. Successful treatment of periodontal disease and dental prophylaxis has been shown to improve clinical outcomes in these systemic conditions. Other systemic conditions associated with periodontal disease include respiratory diseases, Alzheimer's disease, rheumatoid arthritis and chronic kidney disease. Although the underlying mechanisms remain to be fully elucidated, it is generally accepted that the inflammatory burden of chronic periodontal disease has an important systemic impact.

CONCLUSION

Oral-systemic links are multifaceted and complex. While evidence linking periodontal disease with a variety of systemic conditions is still emerging, the nature of the relationship is becoming clearer. The updated understanding of these associations warrants the attention of medical experts and policymakers for a concerted effort to develop a patient-centric, integrated model for the treatment of comorbid dental and medical conditions.

Drug-Loaded Chitosan Scaffolds for Periodontal Tissue Regeneration

Chitosan is a natural anionic polysaccharide with a changeable architecture and an abundance of functional groups; in addition, it can be converted into various shapes and sizes, making it appropriate for a variety of applications. This article examined and summarized current developments in chitosan-based materials, with a focus on the modification of chitosan, and presented an abundance of information about the fabrication and use of chitosan-derived products in periodontal regeneration. Numerous preparation and modification techniques for enhancing chitosan performance, as well as the uses of chitosan and its metabolites, were reviewed critically and discussed in depth in this study. Chitosan-based products may be formed into different shapes and sizes, considering fibers, nanostructures, gels, membranes, and hydrogels. Various drug-loaded chitosan devices were discussed regarding periodontal regeneration.

Randomised controlled trials on prevention, diagnosis and treatment of diabetes in African countries: a systematic review

OBJECTIVES

The epidemiological transition from infectious to chronic diseases leads to novel challenges in African health systems. The prevalence of diabetes mellitus (DM) is increasing dramatically. Undiagnosed and undertreated DM leads to numerous complications including end-organ damage and death. Our objectives were to collect the best locally generated evidence on DM interventions, identify knowledge gaps and determine underexplored research areas.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

PARTICIPANTS AND SETTING

African patients in primary, secondary and tertiary prevention, diagnosis and treatment DM type 1 (DM1), type 2 (DM2) and gestational DM (GDM).

OUTCOME

All-cause mortality, glycaemic control, complications, quality of life, hospital admission, treatment adherence and costs.

DATA SOURCES

Articles published in MEDLINE Ovid, CENTRAL, CINAHL, African Journals Online and African Index Medicus and the International Clinical Trials Registry Platform in English language without time restrictions. The systematic search was last updated in October 2020.

RESULTS

Out of 3736 identified publications, we included 60 eligible studies conducted in 15 countries, 75% were conducted in urban healthcare settings, including 10 112 participants. We included 8 studies on DM1, 6 on GDM, 2 on pre-DM, 37 on mainly DM2 including 7 on DM-related complications. The design of the studied intervention was heterogeneous with a focus on educational strategies. The other studies investigated the efficacy of nutritional strategies including food supplementations, pharmacological strategies and strategies to enhance physical activity. Seven studies included interventions on DM-related complications.

CONCLUSIONS

Research activities increased in recent years, but available evidence is still not representative for all African countries. There is a big lack of evidence in primary healthcare and rural settings, implementation research, pharmacological interventions, especially in poorer countries. Nevertheless, the identified studies offer a variety of effective interventions that can inform medical care and future research.

PROSPERO REGISTRATION NUMBER

CRD42019122785.

Treatment of periodontitis for glycaemic control in people with diabetes mellitus

BACKGROUND

Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis.  Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non-surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care.  OBJECTIVES: To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis.

SEARCH METHODS

An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies.  SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin).

DATA COLLECTION AND ANALYSIS

At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications.

MAIN RESULTS

We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel-RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care.  We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate-certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) -0.59% to -0.28%; -6.4 mmol/mol to -3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI -0.52% to -0.08%; -5.7 mmol/mol to -0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI -0.55% to -0.45%; -6.0 mmol/mol to -4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies.

AUTHORS' CONCLUSIONS

Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate-certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review.

Grafting Resveratrol onto Mesoporous Silica Nanoparticles towards Efficient Sustainable Immunoregulation and Insulin Resistance Alleviation for Diabetic Periodontitis Therapy

The treatment of diabetic periodontitis (DP) has become a tough challenge in dental clinic mainly due to the intrinsic drawbacks of conventional therapy strategy and currently unclear mechanisms to elucidate...

Baseline HbA1c Level Influences the Effect of Periodontal Therapy on Glycemic Control in People with Type 2 Diabetes and Periodontitis: A Systematic Review on Randomized Controlled Trails

INTRODUCTION

The question of whether periodontal therapy is an effective strategy for achieving glycemic control in people with type 2 diabetes mellitus (T2DM) and periodontitis continues to be open to debate. To clarify this issue, we conducted a systematic review and meta-analysis.

METHODS

A systematic literature search of randomized controlled trials (RCTs) was carried out by searching four electronic databases and four journals up to April 2020. RCTs that evaluated the effect of periodontal therapy on glycemic control in people with T2DM were included.

RESULTS

A total of 23 RCTs were included in this systematic review and meta-analysis. We found that after 3 and 6 months, periodontal therapy could significantly reduce glycosylated hemoglobin (HbA1c) level (3-month: weighted mean difference [WMD] - 0.514, 95% confidence interval [CI] - 0.730, - 0.298, p = 0.000; 6-month: WMD - 0.548, 95% CI - 0.859, - 0.238, p = 0.000). However, huge heterogeneity existed. Further analyses on 11 potential sources of heterogeneity found that baseline HbA1c of the included studies was the most significant factor causing heterogeneity. The benefit of periodontal therapy on glycemic control was much more obvious in studies with a higher baseline HbA1c level than in those with a lower baseline HbA1c level.

CONCLUSIONS

Periodontal therapy significantly contributed to glycemic control in T2DM patients, especially in patients with higher baseline HbA1c level.