Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

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

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.     

Serum leveis of inflammatory markers in type 2 diabetes patients with chronic periodontitis

Diabetes has been associated with periodontitis, but the mechanisms through which periodontal diseases affect the metabolic control remain unclear.

Objective

This study aimed to evaluate serum leveis of inflammatory markers, IL-8, IL-6 and monocyte chemoattractant protein 1 (MCP-1), in type 2 diabetic patients in the presence of chronic periodontitis.

Material and Methods

Forty two individuals were enrolled in this study and assigned to one of five groups: diabetes mellitus with inadequate glycemic control and periodontitis (DMI+P, n = 10), diabetes mellitus with adequate glycemic control and periodontitis (DMA+P, n = 10), diabetes mellitus without periodontitis (DM, n = 10), periodontitis without diabetes (P, n=6), and neither diabetes nor periodontitis (H, n = 6). Periodontal clinical examination included visible plaque index (PL), gingival bleeding index (GB), probing depth (PD), attachment level (AL) and bleeding on probing (BP). Glycemic control was evaluated by serum concentration of glycated hemoglobin (HbAlc). Inflammatory serum markers IL-8, IL-6 and (MCP-1) were measured by ELISA.

Results

DMI+P and DMA+P groups presented higher PD (p=0.025) and AL (p=0.003) values when compared to the P group. There were no significant differences among groups for IL-6, IL-8 and MCP-1 serum levels.

Conclusions

Although periodontitis was more severe in diabetic patients, the serum levels of the investigated inflammatory markers did not differ among the groups.     

Diabetes and periodontal disease: two sides of a coin

Diabetes and periodontal disease are two seemingly unrelated disorders whose complex interrelationship is only now being clarified. How does diabetes, a metabolic disease, affect the periodontium? Perhaps even more interesting for the diabetic patient: How does periodontal disease, a bacterial infection that results in inflammation and tissue destruction in the oral cavity, impact the metabolic control of diabetes? Evidence clearly supports diabetes as a risk factor for periodontal disease. The mechanisms by which diabetes adversely influences the periodontium are in many ways similar to the mechanisms responsible for the classic complications of diabetes. In recent years, research has demonstrated that the relationship between periodontal disease and diabetes is more complex than previously realized. Not only does diabetes affect the periodontium, but periodontal infection can adversely impact glycemic control in diabetes. Periodontal treatment that decreases the bacterial challenge and the resulting inflammatory periodontal destruction can improve glycemia in some diabetic patients. These research findings are of importance to diabetic patients and their health care providers, because the findings support the need for examination, diagnosis, treatment, and prevention of periodontal infection.     

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.     

Diagnostic & therapeutic strategies for the management of the diabetic patient

The bridge between oral and systemic health exists and becomes more concrete as data continue to emerge in support of this relationship. The medical management of diabetes is affected by the presence of chronic infections, such as periodontitis. This article reviews the pathogenesis of periodontal disease as it relates to diabetes. The author discusses patient susceptibility in terms of risk and recommends risk assessment to determine optimal treatment strategies. Patients with poorly controlled diabetes are at greater risk for developing periodontitis. The opportunity for systemic exposure to periodontal pathogens and proinflammatory mediators associated with periodontitis is discussed relative to their specific effects on patients with diabetes. The importance of good metabolic control in terms of risk for developing long-term complications of diabetes is presented and the impact of periodontitis on achieving adequate metabolic control is described. Special considerations for the management of patients with diabetes in the dental office are reviewed, including the signs and symptoms of diabetes, risk assessment for diabetes, and the challenges of "tight control" with insulin and oral agents with regards to hypoglycemia. It is recommended by the author that a thorough medical history of the patient be obtained, that the patient's medications are known, that the dentist consults with the patient's physician to assess the patient's glycemic control, and that the patient's blood glucose levels and dietary intake be monitored before treatment. Finally, the author reviews the long-term complications of diabetes, particularly the oral complications that can affect overall health. The author concludes with the belief that the treatment of periodontal diseases should not be considered optional or elective but, instead, should be a necessary and integral part of a patient's overall healthcare program.     

Effects of periodontal disease on glycemic control,complications, and incidence of diabetes mellitus

Diabetes mellitus is a group of metabolic disorders with high mortality and morbidity associated with complications such as cardiovascular disease, kidney disease, and stroke. The prevalence of diabetes is 9.4% in US adults, and prevalence increases markedly with age, with 1 in 4 adults aged ≥65 years affected by diabetes. The estimated number of adults with type 2 diabetes globally almost tripled between 2002 and 2017, reflecting increases seen in the USA and elsewhere. This increase raises concerns about the increased morbidity and mortality associated with the complications of diabetes, including periodontal disease and tooth loss. There is a reciprocal adverse relationship between diabetes and periodontal disease, with diabetes as a major risk factor for periodontal disease, and in those patients with diabetes who also have periodontal disease then there are adverse effects on glycemic control and complications such as cardiovascular disease and end stage renal disease. In this review, those studies detailing the adverse effects of periodontal disease and diabetes will be discussed. Also, evidence is accumulating that periodontitis may play a role in increasing the incidence of new cases of type 2 diabetes, and possibly gestational diabetes. Of course, these studies need to be expanded to better understand the effects of periodontitis on diabetes glycemic control, complications, prediabetes, and the incidence of new cases. However, given the tremendous burden of diabetes on society, the dental profession should be proactive in preventing and treating periodontal disease, not only to preserve the dentition, but also to minimize the adverse effects of periodontitis on diabetes and its complications.     

糖尿病与牙周病相关机制的研究进展

糖尿病和牙周病都是临床常见的慢性高发性疾病,两者互相作用,相互影响。下面从免疫炎症反应、胰岛素抵抗以及牙周治疗对糖尿病患者血糖控制的影响等角度,对目前有关糖尿病与牙周病相关机制的研究进展作一综述。     

2型糖尿病伴慢性牙周炎患者HbAlc含量及血清炎性细胞因子的变化

目的：分析2型糖尿病伴慢性牙周炎患者牙周基础治疗后糖化血红蛋白含量及血清炎性细胞因子的变化。方法：60例2型糖尿病伴慢性牙周炎患者作为研究组,选取同期体检的60例牙周健康者作为对照组。观察并检测两组患者的牙周状况、HbAlc含量及血清炎性细胞因子情况。结果：牙周基础治疗前,研究组患者的白细胞介素?6、肿瘤坏死因子?α、C反应蛋白含量以及HbAlc含量显著高于对照组,差异有统计学意义（ P＜0?05）。牙周基础治疗后,研究组患者的白细胞介素?6、肿瘤坏死因子?α、C反应蛋白含量以及HbAlc含量明显下降,与对照组相比,差异无统计学意义（P＞0?05）。结论：2型糖尿病伴慢性牙周炎患者牙周基础治疗后,可降低糖化血红蛋白含量及血清炎性细胞因子可避免其他并发症的发生及发展。     

Single-blind studies of the effects of improved periodontal health on metabolic control in Type 1 diabetes mellitus

Abstract Uncontrolled studies have suggested a beneficial effect of periodontal treatment on metabolic control of insulin-dependent diabetes mellitus (IDDM). We therefore conducted controlled single-blind studies, using current metabolic status indicators in IDDM subjects free of significant complications other than periodontal diseases. In the 1st study, 41 IDDM subjects with gingivitis and early periodontitis were randomly assigned to treatment (oral hygiene and scaling) or control groups. The study was completed by 16 experimental and 15 control subjects. Reassessment after 2 months showed a Hawthorne effect in the control group, and no difference between groups. However, further analysis showed a relationship between individual metabolic control variation and gingival inflammation. A 2nd study enrolled 23 IDDM subjects with advanced periodontitis, who were randomised to treatment (full initial therapy including root planing) or control groups. Only 1 subject failed to complete the study, owing to illness. In this study, a significant response to periodontal treatment was not accompanied by any improvement in metabolic control. These results support the concept that the effect of metabolic control may be predominant in the relationship between IDDM and periodontal health.     

Insulin resistance and periodontal disease: an epidemiologic overview of research needs and future directions

Poor periodontal health is known to be associated with Type 2 diabetes mellitus (DM). This relationship and underlying mechanisms are discussed elsewhere in this issue. Less is known concerning the link between the metabolic precursors to DM, including insulin resistance (IR), and its possible association with periodontitis. Indeed, there has been relatively little research to date in human populations concerning periodontal disease, IR, and the subsequent risk of chronic diseases, including DM. This paper will present an epidemiologist's view of how IR may link periodontal disease with DM and suggest several avenues of investigation to help clarify some of the outstanding issues.     

Periodontal disease and diabetes mellitus. Bidirectional relationship

Periodontitis is a common problem in patients with diabetes. The relationship between these 2 maladies appears bidirectional--insofar that the presence of one condition tends to promote the other, and that the meticulous management of either may assist treatment of the other. Both diabetes and periodontitis can stimulate the chronic release of proinflammatory cytokines that have a deleterious effect on periodontal tissues. The chronic systemic elevation of proinflammatory cytokines caused by periodontitis may even predispose individuals to the development of type 2 diabetes. Mechanical treatment of periodontitis (scaling and root planing), when combined with short-term administration of therapeutic levels of tetracycline-type antimicrobials, can temporarily improve glycemic control in diabetic patients, especially in those with advanced forms of periodontitis and poor glycemic control before treatment. The biochemical mechanisms suggested by these studies imply that other periodontal procedures designed to rid patients of periodontal pathogens may also improve the management of diabetes. Therefore, the authors suggest that periodontal patients with diabetes be treated in consultation with a periodontist (Figures 3a through 4b).     

Dentists,diabetes and periodontitis

This review updates the relationship between diabetes mellitus and periodontitis. A checklist has been included to assist the general dental practitioner identify individuals with undiagnosed diabetes. The literature indicates a similar incidence of periodontitis exists between well-controlled diabetics and non-diabetics. However, a greater incidence and severity of periodontitis is observed in both Type 1 and 2 long-term diabetics with poor metabolic control. There is an undeniable link between diabetes mellitus and periodontitis with complex interactions occurring between these diseases. A critical review of the literature fails to support the notion that periodontal therapy has a beneficial effect on the long-term control of diabetes. We have explored the associations between periodontitis and diabetes in the hope of providing the general dental practitioner with the knowledge to support the diabetic patient with the best possible dental care and advice.     

Ⅱ型糖尿病患者的牙周病治疗及影响疗效的相关因素分析

目的探索治疗Ⅱ型糖尿病患者牙周炎的方法与影响疗效的相关因素。方法经临床确诊为Ⅱ型糖尿病伴牙周炎的患者91例,根据牙周炎严重程度设计出不同的个体化治疗方案,经多次治疗,2年随访,分析并介绍了对此类患者治疗的方法与经验。结果血糖控制组和术后口腔卫生状况保持良好组的牙周病患者其治疗疗效显著高于血糖未控制组和术后口腔卫生状况保持较差组(P<0.005)。结论血糖的合理控制、牙周局部治疗及术后口腔卫生保健是糖尿病合并牙周病治疗成功的保障。     

口腔卫生指导对2型糖尿病伴慢性牙周炎患者牙周炎症控制及血糖代谢水平的影响

目的探讨口腔卫生指导对2型糖尿病伴慢性牙周炎患者牙周状况和血糖水平的影响。方法 31例2型糖尿病伴慢性牙周炎患者,接受口腔卫生指导后,分别在基线、6周、3个月、6个月、12个月和18个月检测牙周临床指标和血糖代谢指标。牙周临床指标包括:探诊深度、附着丧失、探诊出血、菌斑指数;血糖代谢指标包括:空腹血糖、糖化血红蛋白。结果 31例患者基线、6周、3个月、6个月、12个月和18个月6个时间点的附着丧失量(P=0.003)和探诊出血阳性率(P=0.022)差异有统计学意义;其它指标如探诊深度(P=0.203)、菌斑指数(P=0.087)、空腹血糖(P=0.352)和糖化血红蛋白(P=0.071)的变化没有统计学意义。结论口腔卫生指导可以短期改善2型糖尿病伴慢性牙周炎患者的牙周炎症,但对牙周组织退缩没有更大的帮助,尚不能认为口腔卫生指导对血糖代谢有显著影响。     

Tooth and periodontal clinical attachment loss are associated with hyperglycemia in patients with diabetes

Background: Periodontal disease has been associated with diabetes, but there is still controversy on the relationship between periodontal clinical parameters and glycemic control. The purpose of this study is to assess the relationship between blood glucose levels and clinical parameters of periodontal disease in individuals with diabetes. Methods: A total of 65 individuals with diabetes and 81 individuals without diabetes were included in the study. A full-mouth periodontal examination and preprandial fasting glycemia values were recorded for each individual. Glycosylated hemoglobin was only measured in patients with diabetes. A comparative analysis between groups (Mann-Whitney U test) and a correlation analysis between glycemia and periodontal parameters were performed (Spearman test). Results: Patients without diabetes presented more teeth than individuals with diabetes (P <0.05). Patients with diabetes with periodontitis displayed loss of periodontal clinical attachment compared to patients without diabetes, but the highest value was observed in patients with periodontitis that reported a smoking habit. Furthermore, patients with diabetes with periodontitis presented higher glycemia and glycated hemoglobin values in contrast to patients with gingivitis. Patients with diabetes with hyperglycemia had a higher risk to develop periodontitis (odds ratio = 2.24; 95% confidence interval = 1.02 to 4.93). A positive correlation was observed between glycemia and clinical attachment loss (AL), whereas a negative correlation between glycemia and the number of teeth present was found (P <0.05). Conclusions: Tooth and periodontal AL were increased by hyperglycemia in individuals with diabetes. This study contributes additional evidence that diabetes could aggravate periodontal disease and affect the systemic health of individuals.     

Effects of diabetes mellitus on periodontal and peri-implant conditions: update on associations and risks

Objectives: To review the evidence for the association between diabetes and periodontal and peri-implant conditions and the impact of periodontal therapy in subjects with diabetes.
Material and Methods: A search of MEDLINE-PubMed was performed up to and including December 2007. The search was limited to clinical studies published in English. Publications on animal studies were excluded. The selection criteria included all levels of available evidence.
Results: Evidence on the association between diabetes and periodontitis supports the concept of increased severity but not extent of periodontitis in subjects with poorly controlled diabetes. Subjects with controlled diabetes do not show an increase in extent and severity of periodontitis. Periodontitis is associated with poor glycaemic control and diabetes-related complications. It is inconclusive that periodontal therapy with or without the use of antibiotics results in improvements of glycaemic control and of markers of systemic inflammation. Evidence is lacking to indicate that implant therapy in subjects with diabetes yields long-term outcomes comparable with those of non-diabetic subjects.
Conclusions: Poorly controlled diabetes may be considered a risk factor for increased severity of periodontitis. The effects of periodontal therapy on glycaemic control and systemic inflammation is not proven beyond doubt and need to be confirmed in large-scale randomized-controlled clinical trials.     

Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome

The components of the human body are closely interdependent; as a result, disease conditions in some organs or components can influence the development of disease in other body locations. The effect of oral health upon health in general has been investigated for decades by many epidemiological studies. In this context, there appears to be a clear relationship between deficient oral hygiene and different systemic disorders such as cardiovascular disease and metabolic syndrome. The precise relationship between them is the subject of ongoing research, and a variety of theories have been proposed, though most of them postulate the mediation of an inflammatory response. This association between the oral cavity and disease in general requires further study, and health professionals should be made aware of the importance of adopting measures destined to promote correct oral health. The present study conducts a Medline search with the purpose of offering an update on the relationship between oral diseases and cardiovascular diseases, together with an evaluation of the bidirectional relationship between metabolic syndrome and periodontal disease. Most authors effectively describe a moderate association between the oral cavity and cardiovascular diseases, though they also report a lack of scientific evidence that oral alterations constitute an independent cause of cardiovascular diseases, or that their adequate treatment can contribute to prevent such diseases. In the case of metabolic syndrome, obesity and particularly diabetes mellitus may be associated to an increased susceptibility to periodontitis. However, it is not clear whether periodontal treatment is able to improve the systemic conditions of these patients. Key words:Cardiovascular diseases, periodontitis, metabolic syndrome, obesity, diabetes mellitus.     

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 organizations. The final date for searching for studies was 24 March 2010. Selection criteria: This review studied randomized 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 randomized trials on the effects on people with Type 1 DM.     

Diabetes and periodontal disease: an example of an oral/systemic relationship

Periodontal disease has been identified as a major complication of diabetes mellitus. Diabetics experience increased destruction of periodontal tissues as a result of an abnormal immune response, altered fibroblast function and levels of collagen, as well as the microvascular effects of advanced glycosylation end products (AGE). The accumulation of AGE in the periodontium is correlated with an increase in the level of inflammatory mediators, which are associated with tissue destruction. These inflammatory mediators may contribute to the severity of tissue destruction in diabetics with periodontal disease. The increased prevalence of periodontal disease in diabetics is an example of an oral/systemic relationship. There is evidence that this relationship may be two-dimensional as well, as diabetics with active periodontitis tend to have poor glycemic control when compared to patients without periodontitis.