The relationship between reduction in periodontal inflammation and diabetes control: a report of 9 cases

Effect of Scaling and Root Planing in Conjunction with Antimicrobial Therapy on Glycated Hemoglobin Levels in Type 2 Diabetes Mellitus Patients

Background

Scaling and root planing with systemic doxycycline had an effect on blood glucose levels in type 2 diabetes patients, according to the results of a glycosylated hemoglobin assay. The trial was conducted to determine whether periodontal therapy affected blood sugar regulation as a result of this finding.

Methods

A total of 60 people with type 2 diabetes (diabetes mellitus not caused by insulin deficiency) were split into three groups. Group I (control group) consists of patients who are only taking an oral anti-diabetic medication. Patients on an oral anti-diabetic drug plus scaling and root planing make up group II. Patients on an oral anti-diabetic drug, scaling, root planing, and doxycycline constitute Group III. The patients were re-evaluated for glycated hemoglobin levels and periodontal status using the clinical parameters of gingival index by Loe and Silness and clinical attachment level at baseline, 30th, 60th, and 90th day.

Results

Compared with group II, the findings showed a statistically significant decrease in glycated hemoglobin values (p =0.001) and improvements in clinical attachment level (p =0.022, 0.05) and gingival index (p = 0.009.,01) in group III. In the control group (group I), no such finding was made. The average gingival index, however, increased statistically significantly (p = 0.032, 0.05).

Conclusion

Various studies have been showing the benefits of non-surgical periodontal therapy as a benefit for improving the overall glycemic status of the patient. Non-surgical mechanical periodontal therapy combined with systemic administration of antimicrobials such as doxycycline enhances the metabolic status of type 2 diabetes mellitus patients better than non-surgical mechanical periodontal therapy alone.

Effect of Conventional Periodontal Treatment (Scaling and Root Planing) on Type-2 Diabetic Patient with Moderate Generalized Chronic Periodontitis: A Clinical Study

Background:

The aim is to assess the effect of periodontal therapy and scaling and root planing (SRP) on the metabolic control in Type 2 diabetes mellitus (DM) patients with chronic periodontitis based on the estimation of glycated hemoglobin (HbA1c).

Materials and Methods:

A prospective, comparative, clinical study was performed on 50 patients suffering from Type 2 DM with moderate, generalized chronic periodontitis. Type 2 moderately controlled diabetic patients with HbA1c values within the range of 6%–8% were selected. The parameters recorded were gingival index, plaque index, sulcus bleeding index, probing pocket depth, clinical attachment level, and HbA1c. The recordings were done at baseline and 6 months after SRP procedures.

Results:

Reductions in all the clinical parameters were observed and were found to be statistically significant (P < 0.05).

Conclusion:

SRP resulted in a statistically significant reduction in the clinical parameters and HbA1c. Hence, periodontal treatment should be included in the management of diabetic patients.

Management of Diabetes in People Undergoing Dental Treatment in Primary Care

Diabetes mellitus is a condition resulting from loss of production of insulin, or insufficient production/insulin resistance leading to high blood glucose levels. Management of the condition can be provided in a variety of settings and is tailored to the person's requirements. The condition has a lifelong, systemic impact due to microvascular and macrovascular complications. Diabetes mellitus has dental implications due to increased risk of infections, poor wound healing, rapid progression of periapical pathology, xerostomia, burning mouth syndrome, and a bidirectional link with periodontal disease. Two clinical cases of patients with diabetes are discussed and their dental management described. Many people with diabetes can be treated in primary care, however, some with suboptimal glycaemic control may require specialist input and liaison with the patient's diabetes team.

Oral microbiota-induced periodontitis: a new risk factor of metabolic diseases

It has recently become evident that the periodontium (gingiva, desmodontal ligament, cementum and alveolar bone) and the associated microbiota play a pivotal role in regulating human health and diseases. The oral cavity is the second largest microbiota in the body with around 500 different bacterial species identified today. When disruption of oral cavity and dysbiosis occur, the proportion of strict anaerobic Gram-negative bacteria is then increased. Patients with periodontitis present 27 to 53% more risk to develop diabetes than the control population suggesting that periodontitis is an aggravating factor in the incidence of diabetes. Moreover, dysbiosis of oral microbiota is involved in both periodontal and metabolic disorders (cardiovascular diseases, dyslipidaemia …). The oral diabetic dysbiosis is characterized by a specific bacteria Porphyromonas, which is highly expressed in periodontal diseases and could exacerbate insulin resistance. In this review, we will address the nature of the oral microbiota and how it affects systemic pathologies with a bidirectional interaction. We also propose that using prebiotics like Akkermansia muciniphila may influence oral microbiota as novel therapeutic strategies. The discovery of the implication of oral microbiota for the control of metabolic diseases could be a new way for personalized medicine.

Whole metagenomic shotgun sequencing of the subgingival microbiome of diabetics and non-diabetics with different periodontal conditions

OBJECTIVE

The aim of this study was to use high-resolution whole metagenomic shotgun sequencing to characterize the subgingival microbiome of patients with/without type 2 Diabetes Mellitus and with/without periodontitis.

DESIGN

Twelve subjects, falling into one of the four study groups based on the presence/absence of poorly controlled type 2 Diabetes Mellitus and moderate-severe periodontitis, were selected. For each eligible subject, subgingival plaque samples were collected at 4 sites, all representative of the periodontal condition of the individual (i.e., non-bleeding sulci in subjects without a history of periodontitis, bleeding pockets in patients with moderate-severe periodontitis). The subgingival microbiome was evaluated using high-resolution whole metagenomic shotgun sequencing.

RESULTS

The results showed that: (i) the presence of type 2 Diabetes Mellitus and/or periodontitis were associated with a tendency of the subgingival microbiome to decrease in richness and diversity; (ii) the presence of type 2 Diabetes Mellitus was not associated with significant differences in the relative abundance of one or more species in patients either with or without periodontitis; (iii) the presence of periodontitis was associated with a significantly higher relative abundance of Anaerolineaceae bacterium oral taxon 439 in type 2 Diabetes Mellitus patients.

CONCLUSIONS

Whole metagenomic shotgun sequencing of the subgingival microbiome was extremely effective in the detection of low-abundant taxon. Our results point out a significantly higher relative abundance of Anaerolineaceae bacterium oral taxon 439 in patients with moderate to severe periodontitis vs patients without history of periodontitis, which was maintained when the comparison was restricted to type 2 diabetics.

Linkage of Infection to Adverse Systemic Complications: Periodontal Disease, Toll-Like Receptors, and Other Pattern Recognition Systems

Toll-like receptors (TLRs) are a group of pattern recognition receptors (PRRs) that provide innate immune sensing of conserved pathogen-associated molecular patterns (PAMPs) to engage early immune recognition of bacteria, viruses, and protozoa. Furthermore, TLRs provide a conduit for initiation of non-infectious inflammation following the sensing of danger-associated molecular patterns (DAMPs) generated as a consequence of cellular injury. Due to their essential role as DAMP and PAMP sensors, TLR signaling also contributes importantly to several systemic diseases including cardiovascular disease, diabetes, and others. The overlapping participation of TLRs in the control of infection, and pathogenesis of systemic diseases, has served as a starting point for research delving into the poorly defined area of infection leading to increased risk of various systemic diseases. Although conflicting studies exist, cardiovascular disease, diabetes, cancer, rheumatoid arthritis, and obesity/metabolic dysfunction have been associated with differing degrees of strength to infectious diseases. Here we will discuss elements of these connections focusing on the contributions of TLR signaling as a consequence of bacterial exposure in the context of the oral infections leading to periodontal disease, and associations with metabolic diseases including atherosclerosis and type 2 diabetes.

The Severity of Periodontal Disease is Associated with the Development of Glucose Intolerance in Non-diabetics: The Hisayama Study

Inflammation is hypothesized to play a significant role in the development of type 2 diabetes; however, reports on clinical inflammatory conditions are limited. Studies have suggested that periodontitis affects glucose control in diabetics. This community-based study examined the relationship between periodontitis and glucose tolerance status, including changes in status. The relationship between periodontal condition and the results of a 75-g oral glucose tolerance test was examined in 961 adults in 1998. Deep pockets (mean pocket depth > 2.0 mm) were significantly associated with impaired glucose tolerance and with diabetes as compared with shallow pockets (< 1.3 mm). In the subgroup with normal glucose tolerance 10 years previously, subjects who subsequently developed impaired glucose tolerance were significantly more likely to have deep pockets. Deep pockets were closely related to current glucose tolerance status and the development of glucose intolerance.

Gender Differences in Periodontal Status and Oral Hygiene of Non-Diabetic and Type 2 Diabetic Patients

BACKGROUND

This study investigated gender dependent differences by the comparison of periodontal status and oral hygiene between diabetic patients and non-diabetic subjects.

METHODS

517 mostly obese subjects (171 non-diabetic, 205 type 2 diabetic with oral and 141 with insulin therapy; mean: 59 years) completed an oral hygiene questionnaire and had a clinical examination, including periodontal screening and recording (PSR), percentage of bleeding teeth (PBT), probing pocket depth (PD), gingivitis index (GI), and number of teeth (Tn). Main parameters were "periodontitis" and "oral hygiene behaviour", each defined by 5 sub-parameters. For a comparison of all results, each sub-parameter was set 0.2. The "low performance index" (LoP) was the sum of significantly worse sub-parameters in the compared groups (maximum of low performing = 1.0).

RESULTS

Gender comparison: In non-diabetic and diabetic patients with oral medication, males performed worse (LoP: periodontitis 0.6 - 0.8; oral hygiene 0.4 - 0.6). The male insulin group performed worse oral hygiene (LoP: 0.4) than females with insulin therapy, whereas the periodontal status showed no difference. Diabetic and non-diabetic groups: Females: Diabetic groups performed worse than non-diabetics (LoP: periodontitis 0.2 - 1.0; oral hygiene 0.4). Insulin patients had worse periodontal status and showed no difference in oral hygiene when compared to diabetic patients with oral medication (LoP: 0.2). Males: Diabetic group with oral medication had worse periodontal status than non-diabetics (LoP: 0.6).

CONCLUSIONS

The periodontal status was mainly due to oral hygiene behaviour, which was worse in men. Apparently behaviour and not diabetes is the major determinant of periodontitis. Men apparently need much more advise than women.

Relationship between diabetes and periodontal infection

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

The Effect of Scaling and Root Planing on Glycaemic Control, Periodontal Status and Gingival Crevicular Fluid TNF-α Levels in an Indian Population- To Reveal the Ambivalent Link

CONTEXT

Periodontal disease and diabetes mellitus(DM) share a two - way relationship. It can be hypothesized that successful management of periodontal infection in diabetes will lead not only to reduction of local signs and symptoms of the disease, but also to better control of glucose metabolism.

AIMS

To monitor the effect of Scaling and Root planing (SRP) on glycaemic control in patients with type 2 diabetes mellitus by estimating the HbA1c and GCF TNF-α levels.

SETTINGS AND DESIGN

This Interventional clinicobiochemical study was carried out over a period of 6 months from December 2010-May 2011 in Bengaluru, Karnataka, India.

MATERIALS AND METHODS

Fifteen well-controlled, 15 moderately controlled and 15 poorly controlled diabetic subjects were enrolled in this study. All participants were subjected to non-surgical periodontal (SRP) therapy. GCF sampling and clinical periodontal parameters assessment were done at baseline and 3 months post-therapy. TNF-α levels in GCF were analyzed by enzyme-linked immunosorbent assay (ELISA) at baseline and 3 months post therapy. The improvement in glycaemic control was assessed using HbA1c levels at 3 months reevaluation.

STATISTICAL ANALYSIS

The data obtained were statistically analysed using Kruskal-Wallis test, Mann-Whitney test and Wilcoxon Signed Rank test.

RESULTS

Following periodontal treatment, all patients demon- strated a significant improvement in periodontal status. A reduction in TNF-α level and the HbA1c values were also observed.

CONCLUSION

The result indicates that SRP is effective in improving metabolic control in Type 2 Diabetes Mellitus patients possibly through the reduction of TNF-α which in turn might improve the insulin resistance.

Effects of nonsurgical periodontal therapy on clinical response, microbiological profile, and glycemic control in Malaysian subjects with type 1 diabetes

The association between diabetes mellitus and chronic periodontal disease has long been established. Most of the researches linking these two very common chronic diseases were based on type 2 diabetes mellitus and chronic periodontal disease. However, this study was conducted to investigate the association between type 1 diabetes and chronic periodontal disease in Malaysian subjects. Forty-one Malaysian subjects, of which 20 subjects were type 1 diabetics and with chronic periodontal disease (test group) and 21 subjects with only chronic periodontal disease (control group), were included in the study. Periodontal parameters and plaque samples for microbiological evaluation were done at baseline, 2 and 3 months after nonsurgical periodontal therapy. Blood samples were taken from only the test group and evaluated for HbA1c at baseline and 3 months after periodontal therapy. There were no statistically significant difference in periodontal parameters between groups (P>0.05) and no significant improvement in the level of HbA1c in the test group. Microbiological studies indicated that there were significant reductions in the levels of the tested pathogens in both groups. The results of our study were similar to the findings of several other studies that had been done previously.

Periodontitis and type II diabetes: a two-way relationship

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

Risk factors of periodontal disease: review of the literature

Objectives. This paper aims to review the evidence on the potential roles of modifiable and nonmodifiable risk factors associated with periodontal disease. Data. Original articles that reported on the risk factors for periodontal disease were included. Sources. MEDLINE (1980 to Jan 2014), PubMed (using medical subject headings), and Google Scholar were searched using the following terms in different combinations: "periodontal disease," "periodontitis," "risk factors," and "causal." This was supplemented by hand-searching in peer-reviewed journals and cross-referenced with the articles accessed. Conclusions. It is important to understand the etiological factors and the pathogenesis of periodontal disease to recognize and appreciate the associated risk factors. As periodontal disease is multifactorial, effective disease management requires a clear understanding of all the associated risk factors.

Molecular mechanisms involved in the bidirectional relationship between diabetes mellitus and periodontal disease

Both diabetes and periodontitis are chronic diseases. Diabetes has many adverse effects on the periodontium, and conversely periodontitis may have deleterious effects further aggravating the condition in diabetics. The potential common pathophysiologic pathways include those associated with inflammation, altered host responses, altered tissue homeostasis, and insulin resistance. This review examines the relationship that exists between periodontal diseases and diabetes mellitus with a focus on potential common pathophysiologic mechanisms.

Dietary behaviors and oral-systemic health in women

The impact of dietary behaviors and food consumption and their relation to oral health are significant public health issues. Women and men exhibit different dietary behaviors. Understanding the influences of dietary behaviors on oral health from the perspective of gender disparities, however, is limited. This article provides the intersections of dietary factors and oral-systemic health for which women are at greater risk than men. Topics include the effect of dietary choices on oral health disparities seen in female patients. Interventional strategies at the local and community level that are designed to influence the balance between dietary habits and oral-systemic health are discussed.

Effects of periodontal non-surgical therapy plus azithromycin on glycemic control in patients with diabetes: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Periodontitis may alter the systemic condition in patients with diabetes and hence interfere with glycemic control. The objective of this study was to determine the quantifiable changes in glycated hemoglobin (HbA1C) after periodontal non-surgical therapy plus azithromycin in a mixed population of patients with poorly controlled diabetes.

MATERIALS AND METHODS

One hundred and five patients were randomized to receive non-surgical therapy plus azythromycin (AZ-Sca =33), non-surgical therapy plus placebo (PB-Sca = 37) and supragingival prophylaxis plus azithromycin (AZ-Pro = 35). Glycated hemoglobin, glycemia and periodontal parameters were measured at baseline, 3, 6 and 9 mo after treatment.

RESULTS

Periodontal parameters were improved in the AZ-Sca and PB-Sca groups as compared to the AZ-Pro group. A greater reduction in probing depth was observed in the AZ-Sca as compared to the PB-Sca group. Improvement in clinical attachment level was similar between AZ-Sca and PB-Sca groups. A reduction from 8.0% to 7.2% (∆0.8%; p < 0.05) in HbA1C was observed in the AZ-Sca at 9 mo as compared to the PB-Sca group in which the reduction was from 7.9% to 7.6% (∆0.3%). There was no decrease in HbA1C in the AZ-Pro group over time. Mean glycemia values decreased from 195 mg/dL to 159.2 mg/dL (∆35.8 mg/dL; p < 0.05) in the AZ-Sca group whereas a decrease from 194 mg/dL to 174.8 mg/dL (∆19.2 mg/dL) in the PB-Sca group at 9 mo was observed. There were no differences between the AZ-Sca and PB-Sca groups for glycemic parameters. No improvement in glycemic values in the AZ-Pro group was observed.

CONCLUSIONS

A modest improvement in glycemic control was detected with a trend towards the use of non-surgical therapy plus AZ as compared to the placebo.

Periodontal disease and diabetes mellitus

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background:

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

Materials and Methods:

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

Statistical Analysis:

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

Results:

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

Conclusion:

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

Diabetes and periodontal disease

Diabetes mellitus is a systemic disease characterized by increased blood glucose levels and abnormalities of lipid metabolism due to absence or decreased level of insulin. It affects all the body organs and their functions either directly or indirectly. Every dentist should have a basic understanding of the etiopathogenesis, oral and systemic manifestations of this disease. The periodontal diseases are a consequence of extension of the gingival inflammation into the underlying supporting structures of the periodontium, initiated by the presence of plaque and its products on the surfaces of the teeth and the adjoining structures. The progression of periodontal disease is influenced by variety of factors like microorganisms, host response, systemic background, and genetic makeup of the host. Amongst them, diabetes mellitus tops the list. Diabetes and periodontitis influence the clinical outcome of each other and control of both influences the clinical improvement of each.

The relationship between periodontal disease and diabetes mellitus

Periodontitis is a common complication in patients with diabetes. Their classificationis complex and it is based on the clinical presentation, rate of disease progression,age at diagnosis and local and systemic factors that may multiply the risk. The twomajor stages of periodontal diseases are gingivitis and periodontitis. Therelationship between these two diseases appears bidirectional insofar that theexistence of one disease tends to promote the other and that the meticulousmanagement of either may help the treatment of the other. Treatment of periodontitisusing a association of mechanical therapy, scaling and root planning, plus systemictetracycline antibiotics has been demonstrated to have important reductions inHbA1c values. Therefore, for a better control of diabetes we suggest that periodontalpatients with diabetes should be consulted and treated by a periodontist.

Efficacy of short-term adjunctive subantimicrobial dose doxycycline in diabetic patients--randomized study

OBJECTIVE

To investigate the effectiveness of short-term adjunctive subantimicrobial dose doxycycline (SDD) treatment in patients with diabetes mellitus type 2 and chronic periodontitis (CP).

METHODS

Thirty-four patients with CP and type 2 diabetes mellitus were included in the placebo-controlled, double-blind study. After scaling and root planing (SRP), patients were randomly assigned to two groups, receiving either SDD or placebo bid for 3 months. The probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), approximal plaque index, glycated hemoglobin (HbA1c) level were recorded and gingival crevicular fluid (GCF) samples were collected at baseline and after 3-month therapy for the estimation of matrix metalloproteinase-8 levels.

RESULTS

Clinical attachment level, PD, and BOP improved significantly in both groups after therapy (P < 0.05). The statistically significant difference between the two groups after the therapy was observed only in PD in tooth sites with initial PD ≥ 4 mm (SRP + placebo: 3.41 ± 0.6 mm vs SRP + SDD: 2.92 ± 0.5 mm, P < 0.05). GCF matrix metalloproteinase-8 levels were significantly reduced only in SRP + SDD group (P < 0.01). There were no changes in HbA1c levels after therapy.

CONCLUSION

The short-term administration of SDD gives significant benefit at tooth sites with moderate disease (PD ≥ 4 mm) when compared to SRP alone in patients with diabetes and CP.

Gut microbiota and diabetes: from pathogenesis to therapeutic perspective

More than several hundreds of millions of people will be diabetic and obese over the next decades in front of which the actual therapeutic approaches aim at treating the consequences rather than causes of the impaired metabolism. This strategy is not efficient and new paradigms should be found. The wide analysis of the genome cannot predict or explain more than 10-20% of the disease, whereas changes in feeding and social behavior have certainly a major impact. However, the molecular mechanisms linking environmental factors and genetic susceptibility were so far not envisioned until the recent discovery of a hidden source of genomic diversity, i.e., the metagenome. More than 3 million genes from several hundreds of species constitute our intestinal microbiome. First key experiments have demonstrated that this biome can by itself transfer metabolic disease. The mechanisms are unknown but could be involved in the modulation of energy harvesting capacity by the host as well as the low-grade inflammation and the corresponding immune response on adipose tissue plasticity, hepatic steatosis, insulin resistance and even the secondary cardiovascular events. Secreted bacterial factors reach the circulating blood, and even full bacteria from intestinal microbiota can reach tissues where inflammation is triggered. The last 5 years have demonstrated that intestinal microbiota, at its molecular level, is a causal factor early in the development of the diseases. Nonetheless, much more need to be uncovered in order to identify first, new predictive biomarkers so that preventive strategies based on pre- and probiotics, and second, new therapeutic strategies against the cause rather than the consequence of hyperglycemia and body weight gain.

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

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Periodontitis and risk of diabetes mellitus

Diabetes mellitus (DM) is a complex disease with varying degrees of systemic and oral complications. The periodontium is also a target for diabetic damage. Diabetes is a pandemic in both developed and developing countries. In recent years, a link between periodontitis and diabetes mellitus has been postulated. The oral cavity serves as a continuous source of infectious agents that could further worsen the diabetic status of the patient and serve as an important risk factor deterioration of diabetes mellitus. The present review highlights the relationship between diabetes mellitus and periodontitis. The potential mechanisms involved in the deterioration of diabetic status and periodontal disease are also discussed.

The effect of full-mouth tooth extraction on glycemic control among patients with type 2 diabetes requiring extraction of all remaining teeth: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Several studies have shown that periodontitis can complicate the severity of diabetes by worsening the degree of glycemic control. The purpose of this study was to determine the effect of full-mouth tooth extraction on glycemic control among type 2 diabetic patients.

MATERIAL AND METHODS

A total of 58 patients with type 2 diabetes mellitus and advanced periodontitis who were requiring extraction of all remaining teeth were randomized consecutively into treatment (full-mouth tooth extraction) and control groups (no treatment). Eight patients were lost to follow-up or reported use of antibiotics, leaving 50 patients to be included in the analysis. All patients had all their remaining teeth in a hopeless condition. Relevant data were collected, and glycosylated hemoglobin (HbA(1c) ) and fasting blood glucose levels were measured at baseline and at follow-up times of 3 and 6 mo.

RESULTS

At baseline, the mean (SD) HbA(1c) level was 8.6% (1.24) in the treatment group and 7.7% (0.87) in the control group. In the treatment group, the mean HbA(1c) level decreased significantly from 8.6% at baseline to 7.4% after 3 mo of denture treatment, and continued to decrease to 7.3% after 6 mo. In the control group, the mean HbA(1c) decreased from 7.7% at baseline to 7.5% after 3 mo, and remained almost the same after 6 mo. After adjusting for the baseline HbA(1c) , the mean reduction in HbA(1c) after 3 mo in the treatment group [1.23% (0.79)] was significantly higher than the mean reduction in the control group [0.28% (0.87)].

CONCLUSION

Full-mouth tooth extraction resulted in an improvement in glycemic control among diabetic patients. Large-scale multicentre clinical trials are needed to confirm the current evidence.

[The integrality of the attention in diabetics with periodontal disease]

The aim of this study was to evaluate the periodontal conditions of individuals with diabetes and to analyze how SUS has contributed to the health attention of these people in Belo Horizonte, Minas Gerais State. For that, a sample of 300 individuals was selected and interviews with diabetics and health unit managers were conducted. From those, 55% presented gingivitis, 35.3% periodontitis and 9.7% were healthy. As for the integral attention for diabetics in SUS, it was observed that despite the fact that most of them were under medical supervision, only 27.3% were under dental treatment in basic health care units, 3.6% had specialized dental care and only 3.4% were seen by other health workers. Interdisciplinary care and attention in all levels of the system are essential factors for the integrality of health actions.

Treatment of periodontal disease for glycaemic control in people with diabetes

BACKGROUND

Glycaemic control is a key issue in the care of people with diabetes mellitus (DM). Some studies have suggested a bidirectional relationship between glycaemic control and periodontal disease.

OBJECTIVES

To investigate the relationship between periodontal therapy and glycaemic control in people with diabetes and to identify the appropriate future strategy for this question.

SEARCH STRATEGY

A comprehensive approach was adopted employing handsearching; searching of electronic databases including the Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, ZETOC, ISI Web of Knowledge and LILACS; contact with appropriate non-English language healthcare professionals; authors and organisations. The final date for searching for studies was 24th March 2010.

SELECTION CRITERIA

This review studied randomised controlled trials of people with Type 1 or 2 diabetes mellitus (DM) with a diagnosis of periodontitis. Suitable interventions included mechanical periodontal therapy with or without adjunctives and oral hygiene education.

DATA COLLECTION AND ANALYSIS

The titles and abstracts of 690 papers were examined by two review authors independently. Ultimately, seven studies were included and 19 excluded after full text scrutiny. All trials were assessed for risk of bias.

MAIN RESULTS

Three studies had results pooled into a meta-analysis. The effect for the mean percentage difference in HbA1c for scaling/root planing and oral hygiene (+/- antibiotic therapy) versus no treatment/usual treatment after 3/4 months was -0.40% (95% confidence interval (CI) fixed effect -0.78% to -0.01%), representing a statistically significant reduction in HbA1c (P = 0.04) for scaling/root planing. One study was assessed as being at low risk of bias with the other two at moderate to high risk of bias. A subgroup analysis examined studies without adjunctive antibiotics -0.80% (one study: 95% CI -1.73% to 0.13%; P = 0.09), with adjunctive antibiotics in the test group -0.36% (one study: 95% CI -0.83% to 0.11%; P = 0.14), and with antibiotics in both test and control groups after 3/4 months -0.15% (one study: 95% CI -1.04% to 0.74%; P = 0.74).

AUTHORS' CONCLUSIONS

There is some evidence of improvement in metabolic control in people with diabetes, after treating periodontal disease. There are few studies available and individually these lacked the power to detect a significant effect. Most of the participants in the study had poorly controlled Type 2 DM with little data from randomised trials on the effects on people with Type 1 DM.Improving periodontal health is an important objective in itself. However, in order to understand the potential of this treatment to improve glycaemic control among people with diabetes, larger, carefully conducted and reported studies are needed.

Status of association studies linking diabetes mellitus and periodontal disease in India

BACKGROUND

The prevalence of diabetes mellitus (DM) and periodontal disease / periodontitis (PD) is high, and the association of these two as risk factors influencing each other has been recognized and is extensively documented. However, a majority of these association studies have been done in developed countries and / or in developing countries other than India.

OBJECTIVE

To review, quantify and qualify the status of the published indexed scientific literature regarding the bidirectional association of DM and PD in India.

METHOD

An internet search of the literature was conducted to examine relevant association studies of DM and PD in India. As a matter of interest, the related articles were searched manually from one non-indexed national (India) publication of periodontology until October 2008. Specific focus was on indexed literature and only these were considered for the review.

RESULT

Eleven pertinent indexed publications addressing the concern with regard to population in India were identified. Most of them were in agreement with the accepted mechanisms involving these two diseases, but more supported a unidirectional view of interaction, that is, advocating the role of DM in a worsened periodontal condition. One study with an opposite view was recognised.

CONCLUSION

The paucity of such research in India, which will be a hub of diabetics in the near future, reflects the need to make available a strong body of evidence in the indexed literature relating not only to DM and its 'sixth complication', PD, but also the strong influence of PD on DM.

The effect of intensive oral hygiene care on gingivitis and periodontal destruction in type 2 diabetic patients

PURPOSE

This study aimed to investigate the effects of oral hygiene care by oral professionals on periodontal health in type 2 diabetes mellitus patients.

MATERIALS AND METHODS

Diabetic participants were recruited at a university hospital and matched at a 1:1 ratio by age and gender, and randomly allocated into intervention (40 people) and control groups (35 people). Tooth brushing instruction, oral health education, and supra-gingival scaling were implemented in all patients at baseline. This program was repeatedly conducted in intervention patients every month for 6 months, and twice at baseline and the sixth month in the control. Oral health was measured by decayed, missing, and filled teeth (DMFT), plaque index, calculus index, bleeding index, patient hygiene performance (PHP) index, tooth mobility, Russel's periodontal index, and community periodontal index (CPI). Diabetes-related factors, oral and general health behaviors, and sociodemographic factors were interviewed as other confounding factors. An analysis of covariance (ANCOVA) was used with SPSS for Windows 14.0.

RESULTS

At baseline, there were no significant differences between the two groups in average of periodontal health (calculus index, bleeding index, Russel's periodontal index, CPI, and tooth mobility), diabetes-related factors (fasting blood glucose, postprandial blood glucose, and HbA1c), and in distribution of sociodemographic factors and health behaviors. In intervention group, plaque index, dental calculus index, bleeding index, and PHP index were reduced fairly and steadily from the baseline. There were significant differences in plaque index, dental calculus index, bleeding index, PHP index, and Russel's periodontal index between the two groups at sixth month after adjusted for baseline status.

CONCLUSION

Intensive oral hygiene care can persistently improve oral inflammation status and could slow periodontal deterioration.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and laboratory evaluations of non-surgical periodontal treatment in subjects with diabetes mellitus

BACKGROUND

The aim of this study was to evaluate the clinical and laboratory changes 3 months after full-mouth scaling and root planing in subjects with and without diabetes mellitus.

METHODS

This study was performed using 10 subjects with type 2 diabetes mellitus who required insulin therapy (DM) and 10 healthy adult control subjects (NDM) with generalized chronic periodontal disease. Both groups were treated with full-mouth scaling and root planing and given oral hygiene instructions. Clinical parameters, including plaque index (PI), gingival index (GI), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL), were measured at four sites per tooth. Subgingival plaque samples were obtained from sites with the deepest PD (> or =5 mm) and with furcations in each subject. Samples were also tested for the presence of Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis, and Tannerella forsythia (previously T. forsythensis) by polymerase chain reaction. Glycemic control (glycosylated hemoglobin [HbA1c] and fasting glucose levels) and clinical and microbiologic assessments were recorded at baseline and 3 months after periodontal treatment.

RESULTS

Data revealed statistical changes (P < or =0.05; analysis of variance [ANOVA]) in clinical variables (PI, GI, PD, GR, and CAL) between baseline and 3 months in both groups. Conversely, no improvement in the fasting glucose level or glycosylated hemoglobin (P < or =0.05; ANOVA) was found after treatment. Besides some reduction in the bacterial frequency 3 months after treatment, no statistically significant difference was found between the groups.

CONCLUSION

Clinical and laboratory responses were similar in DM and NDM groups 3 months after full-mouth scaling and root planing.

Effect of periodontitis on insulin resistance and the onset of type 2 diabetes mellitus in Zucker diabetic fatty rats

BACKGROUND

Studies indicate that an association exists between periodontitis and type 2 diabetes mellitus (T2DM) and/or obesity, with chronic inflammation hypothesized as the common denominator. The purpose of this study was to determine the causal effect of periodontitis and the concomitant impact of diet on the onset of insulin resistance (IR) and T2DM using a rat model system that simulates human obesity and T2DM.

METHODS

Twenty-eight, 5-week-old female Zucker diabetic fatty (ZDF, fa/fa) rats were divided into four groups of seven animals: high-fat fed-periodontitis (HF/P), high-fat fed-no periodontitis (HF/C), low-fat fed-periodontitis (LF/P), and low-fat fed-no periodontitis (LF/C). Periodontitis was induced by ligature placement. Fasting plasma insulin and glucose levels were measured, and glucose tolerance tests were performed to assess glucose homeostasis, IR, and the onset of T2DM. The level of tumor necrosis factor-alpha (TNF-alpha), leptin, triglycerides, and free fatty acids were determined in week 13 at sacrifice.

RESULTS

HF/P rats developed more severe IR compared to HF/C rats (P <0.01) and LF/P or LF/C rats (P <0.001) as measured by fasting insulin levels and homeostasis model assessment analysis. The onset of severe IR occurred approximately 3 weeks earlier in HF/P rats compared to HF/C rats. HF/P rats developed impaired (110 to 125 mg/dl) and frank fasting hyperglycemia (>125 mg/dl) 2 weeks earlier than HF/C rats. There was no difference in the severity and onset of IR and T2DM between LF/P and LF/C rats. The level of TNF-alpha was significantly higher in HF/P rats compared to HF/C rats (P <0.01).

CONCLUSION

Periodontitis accelerated the onset of severe IR and impaired glucose homeostasis in high-fat fed ZDF rats.

Salivary lysozyme and prevalent hypertension

Although the etiology of essential hypertension is not clearly understood, endothelial dysfunction from chronic infection and/or impaired glucose metabolism may be involved. We hypothesized that salivary lysozyme, a marker for oral infection and hyperglycemia, might display a significant relationship with hypertension, an early stage of cardiovascular disease. Logistic regression analyses of the Kuopio Oral Health and Heart Study demonstrated that persons with higher lysozyme levels were more likely to have hypertension, after adjustment for age, gender, smoking, BMI, diabetes, the ratio of total cholesterol to HDL cholesterol, and C-reactive protein. The exposure to increasing quartiles of lysozyme was associated with adjusted Odds Ratios for the outcome, hypertension, 1.00 (referent), 1.25, 1.42, and 2.56 (linear trend p < 0.003). When we restricted the sample to the individuals without heart disease (N = 250), we observed a non-significant trend for increasing odds. Our hypothesis--"high salivary lysozyme levels are associated with the odds of hypertension"--was confirmed.

Periodontal disease: associations with diabetes, glycemic control and complications

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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