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.     

The effect of periodontal treatment on glycemic control in patients with type 2 diabetes mellitus

BACKGROUND, AIMS: This study was designed to explore the effect of periodontal therapy on glycemic control in persons with type 2 diabetes mellitus (DM). METHODS: 36 patients with type 2 DM (treatment group) received therapy for adult periodontitis during an 18-month period. A 36-person control group was randomly selected from the same population of persons with type 2 DM who did not receive periodontal treatment. RESULTS: These groups were well matched for most of the parameters investigated. During the nine-month observation period, there was a 6.7% improvement in glycemic control in the control group when compared to a 17.1% improvement in the treatment group, a statistically significant difference. Several parameters that could confound or moderate this glycemic control were explored. These included the treatment of non-dental infections, weight and medication changes. No moderating effect was associated with any of these variables. However, there were too few subjects in the study to have the statistical power necessary to assess these possible moderators of glycemic control. CONCLUSIONS: We interpret the data in the study to suggest that periodontal therapy was associated with improved glycemic control in persons with type 2 DM.     

Effect of non-surgical periodontal therapy on glycemic control in patients with type 2 diabetes mellitus

BACKGROUND: The literature suggests that an alteration in glucose metabolism occurs as a result of antibacterial periodontal therapy. The objective of this study was to monitor the effect of non-surgical periodontal therapy on glycemic control in patients with type 2 diabetes mellitus (DM). METHODS: Thirty type 2 DM subjects with periodontitis were randomly divided into two groups. Group 1 (G1), 15 subjects, received one-stage full-mouth scaling and root planing (FMSRP) plus amoxicillin/clavulanic acid 875 mg; group 2 (G2), 15 patients, received only FMSRP. At baseline and after 3 months, the glycated hemoglobin (HbA1c) values, fasting glucose, and clinical parameters (with computerized probing and individualized acrylic stents) were recorded. Following therapy, the subjects were enrolled in a 2-week interval maintenance program for 3 months. RESULTS: After treatment, both groups showed clinical improvements. A probing depth (PD) reduction of 0.8 +/- 0.6 mm (P < 0.05) occurred in G1 and 0.9 +/- 0.4 mm in G2 (P < 0.05), but there were no significant changes in attachment level. Treatment reduced the HbA1c values after the 3-month observation period in both groups; however, the reduction in HbA1c values for the G2 group was statistically significant, but not for the G1 group. The changes in fasting glucose levels were not significant for either group. CONCLUSIONS: Periodontal therapy improved glycemic control in patients with type 2 DM in both groups; however, the reduction in HbA1c values reached statistical significance only in the group receiving scaling and root planing alone [correction].     

Relation between periodontal disease and diabetes mellitus

A study is made of a group of 67 persons with diabetes mellitus, over 15 years of age, in order to know the presence and severity of periodontal disease, in relation with degree of oral hygiene, age, duration of the course and degree of metabolic control of diabetes. It was shown that 85.1% of the cases had some form of the periodontal disease, the most frequent of which being advanced periodontitis (34.3%). 100% of the patients had an inadequate oral hygiene. Lack of metabolic control, age and degree of oral hygiene correlated positively with the severity of periodontal disease.     

Type 2 diabetes mellitus and periodontal disease

The relationship between type 2 diabetes mellitus and periodontal disease was evaluated in 2,878 Pima Indians of the southwestern United States. Two independent measures of periodontal disease, probing attachment loss and radiographic bone loss, were used to compare prevalence and severity of periodontal disease in diabetic and nondiabetic subjects. In all age groups studied, subjects with diabetes had a higher prevalence of periodontal disease, indicating that diabetes may be a risk factor for periodontal disease.     

Effects of periodontal therapy on glycemic control and inflammatory markers

BACKGROUND: Periodontitis, a complication of diabetes mellitus (DM), can induce or perpetuate systemic conditions. This double-masked, placebo-controlled study evaluated the effects of periodontal therapy (scaling and root planing [SRP]) on the serum levels of glycated hemoglobin (HbA1c) and on inflammatory biomarkers. METHODS: Thirty subjects with type 2 DM and periodontitis were treated with SRP + placebo (SRP; N = 15) or with SRP + doxycycline (SRP+Doxy; N = 15), 100 mg/day, for 14 days. Clinical and laboratory data were recorded at baseline and at 3 months after treatment. RESULTS: After 3 months, the reduction in probing depth was 0.8 mm for the SRP group (P <0.01) and 1.1 mm for the SRP+Doxy group (P <0.01) followed by a 0.9% (SRP; P = 0.17) and 1.5% (SRP+Doxy; P <0.01) reduction in HbA1c levels. A significant reduction in interleukin (IL)-6; interferon-inducible protein 10; soluble fas ligand; granulocyte colony-stimulating factor; RANTES; and IL-12 p70 serum levels were also verified (N = 30). To our knowledge, this is the first report on the effects of periodontal therapy on multiple systemic inflammatory markers in DM. CONCLUSIONS: Periodontal therapy may influence the systemic conditions of patients with type 2 DM, but no statistical difference was observed with the adjunctive systemic doxycycline therapy. Moreover, it is possible that the observed improvement in glycemic control and in the reduction of inflammatory markers could also be due to diet, which was not controlled in our study. Therefore, a confirmatory study with a larger sample size and controlled diet is necessary.     

Effects of glycemic control on saliva flow rates and protein composition in non-insulin-dependent diabetes mellitus

Objective. The objective of this study was to determine whether improvements in the level of diabetic control in a group of subjects with poorly controlled non-insulin-dependent diabetes mellitus influence salivary output and composition.Study design. Repeated whole unstimulated and stimulated parotid saliva samples were collected from diabetic patients attending an outpatient diabetes education program and a matched nondiabetic control group. Saliva was analyzed for flow rates, parotid protein concentration and composition, and amylase activity. Subjective responses to questions about salivary hypofunction were tested.Results. There were no significant differences in whole unstimulated and stimulated parotid flow rates or stimulated parotid protein concentration and composition between diabetics and the control group. Amylase activity was higher in diabetics and decreased with improved glycemic control. Subjects reporting taste alterations had higher mean blood glucose levels than subjects with normal taste sensation.Conclusions. Poorly controlled non-insulin-dependent diabetes mellitus has no influence on saliva output, although amylase activity may be elevated, and there may be taste alterations.     

牙周病与妊娠期糖尿病关系的临床研究

目的 研究牙周病与妊娠期糖尿病的相关性,探讨牙周炎对妊娠期糖尿病血清C-反应蛋白的影响.方法 选择24～28周孕妇中,患有妊娠期糖尿病孕妇100例纳入试验组,身体健康孕妇100例作为对照组,检查其牙周健康指数,其中包括牙龈指数、龈沟出血指数、附着丧失水平、牙周袋探诊深度,统计分析两组差别.同时在试验组孕妇中选取伴牙周炎和牙周健康的孕妇各30例,检测其血清C-反应蛋白的含量,进行统计学分析.结果 除牙周探诊深度外,两组孕妇的其他牙周健康指数均的差异有统计学意义(P＜0.05),试验组牙周炎孕妇的血清C-反应蛋白水平显著高于同组牙周健康的孕妇(P＜0.05).结论 牙周病与妊娠期糖尿病具有相关性,牙周炎症可能是妊娠期糖尿病的危险因素之一.     

A longitudinal study on insulin-dependent diabetes mellitus and periodontal disease

Abstract In the present two-year longitudinal investigation, the progression of periodontal disease was assessed after 1 year from the baseline examination in 38 dentate subjects and after 2 years in 22 dentate subjects with a mean duration of 18 years of insulin-dependent diabetes mellitus. The diabetics, aged 35 to 56 years at baseline, were under medical treatment at the outpatient clinic of the III Department of Medicine, University Central Hospital of Helsinki and at 2 diabetic clinics of the Helsinki Health Centre. Based upon their long-term medical records, 26 subjects were at baseline identified as having poorly controlled insulin-dependent diabetes (PIDD) with a mean blood glucose level of 12.5 mmol/1 and a mean glycosylated hemoglobin (HBA₁) level of 10.1%. 12 subjects were classified as having controlled insulin-dependent diabetes (CIDD) with a mean blood glucose level of 6.7 mmol/1 and a mean HBA, level of 9.2% at baseline. For each individual, recordings were made at baseline and after 1 and 2 years from the baseline for the plaque index, gingival index, pocket depth, loss of attachment, bleeding after probing, gingival recession, and radiographic loss of alveolar bone. At baseline and 2 years after the baseline examination, the PIDD subjects had similar plaque conditions as the CIDD subjects. At baseline and after 1 and 2 years from baseline the PIDD subjects had more gingivitis and bleeding after probing (P<0.05, χtest) than the CIDD subjects. Both at baseline and at the 1-year and 2-year examinations, the long-term PIDD subjects had lost more tooth attachment and approximal bone than the corresponding CIDD subjects (P<0.01, χ-test). At all 3 examinations, the PIDD subjects also exhibited more gingival recession than the CIDD subjects (P<0.05, χ-test).     

Negative effects of chronic inflammatory periodontal disease on diabetes mellitus

Periodontal disease is the result of a complex interplay of bacterial infection and host responses, and is often modified by various systemic diseases such as diabetes mellitus. Such diseases are capable of affecting the periodontium and/or the treatment of periodontal disease. However, recent research has changed our concept of how periodontal disease should be treated. Here we present several concerns directed towards the periodontal therapy of patients with diabetes mellitus based on our studies. When treating periodontitis patients who have diabetes mellitus it is important to consider the type of diabetes. Patients with non-insulin dependent diabetes mellitus can be further classified according to the degree of insulin resistance, since recent epidemiological studies have suggested that successful anti-microbial therapy might result in improved insulin resistance in highly insulin resistant patients. Because the major contributing factor for insulin resistance is currently considered to be the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), and because periodontal surgery may cause transient bacteremia which may up-regulate the serum TNF-alpha level, which in turn suppresses insulin action, patients should be strictly treated non-surgically and their serum TNF-alpha levels should be periodically monitored. On the other hand, diabetic patients positive for serum anti-glutamate decarboxylase auto-antibody should be examined for the source of this antibody, since 1) gingival and periodontal ligament fibroblasts were found to express glutamate decarboxylase, and 2) some otherwise healthy periodontitis patients develop anti-glutamate decarboxylase antibody. Thus, chronic periodontitis may influence the level of this antibody which is widely used as a predictive marker for slowly progressive insulin dependent diabetes mellitus. Not only is periodontal disease thereby affected by systemic diseases, but carefully managed periodontal therapy may also have a positive effect on the general health of patients with systemic diseases.     

Relationship between markers of metabolic control and inflammation on severity of periodontal disease in patients with diabetes mellitus

AIM: The aim of this study was to investigate the relationship between markers of metabolic control and inflammation and periodontal disease parameters in patients with diabetes. MATERIAL & METHODS: One hundred and eighty one adult patients with diabetes attending treatment at two diabetes centres were invited to participate in the study. Periodontal examination included full-mouth assessment for probing depths and bleeding on probing (BOP). Blood analyses were carried out for glycated haemoglobin, (HbA1c), high-sensitivity C reactive protein, (hsCRP) and lipid profile comprising total cholesterol, low-density lipoprotein cholesterol (LDL chol), high-density lipoprotein cholesterol (HDL chol) and triglycerides. RESULTS: Upon multivariate analysis, periodontal disease severity in terms of increased percentage of BOP and mean percentage of sites with probing depths > or = 5 mm were found to be associated with inadequate glycaemic control as measured by HbA1c (p<0.01). HsCRP was also found to be a significant predictor for mean percentage of sites with probing depths > or = 5 mm (p<0.05). After controlling for age, gender, smoking habits and number of teeth, positive correlations were found between HbA1c and percentage sites with probing depths > or = 5 mm, percentage sites BOP, total cholesterol, LDL chol and triglycerides (p<0.05). Using the adjusted differences, subjects with acceptable glycaemic control (HbA1c < 8%) showed a lower percentage of sites with BOP and probing depths > or = 5 mm (p<0.05) when compared with those having inadequate glycaemic control. There was also a trend towards lower blood cholesterol in the well-controlled group. CONCLUSION: The level of glycaemic control as measured by HbA1c emerged as the most consistent risk factor associated with the extent and severity of periodontal disease in this study cohort.     

Improved metabolic control, clinical periodontal status and subgingival microbiology in insulin-dependent diabetes mellitus

The effect of improved metabolic control on the clinical periodontal condition and the subgingival microflora of diseased and healthy periodontal pockets in 6 ambulatory insulin-dependent diabetes mellitus (IDDM) patients was prospectively studied. Duplicate measurements with a time-interval of 3 days were made every 4 moths for assessment of the metabolic status, the clinical periodontal condition and the subgingival microflora. During the study, patients maintained personal oral hygiene measures as they usually did before the study. Neither supplementary dental prophylaxis nor oral hygiene measures were applied during the investigation. Long-term metabolic control (HbAlc) improved significantly with intensive conventional insulin treatment. Gingival redness decreased significantly whereas gingival swelling showed a not significant trend to decrease. It is suggested that microvascular changes associated with improved metabolic control in diabetes mellitus may mediate the observed change in gingival redness. No effect could be demonstrated for probing pocket depth, probing attachment level, bleeding on probing and the plaque index. Statistical analysis of the effect of improved metabolic control on the subgingival microflora revealed that only the % of streptococci increased significantly in diseased periodontal pockets. In general, no significant changes were found in either healthy or diseased pockets with regard to the bacterial flora associated with periodontal disease. The results of the present study indicate that improved metabolic control in IDDM patients may have no potential impetus for an improved clinical periodontal condition nor on the subgingival bacterial flora. It is concluded that the periodontal condition in IDDM patients may only ameliorate when local oral hygiene measures are applied.     

Prevalence of periodontal pathogens with varying metabolic control of diabetes mellitus

Abstract. The purpose of this study was to determine the prevalence of 5 periodontal pathogens in individuals with diabetes mellitus. Subjects ( n = 107) 20–70 years of age with type 1 ( n = 60) or 2 ( n = 47) diabetes mellitus were studied for the occurrence of the periodontal pathogens A. actinomycetemcomitans, F. nude-alum, E. corrodens, P. gingivalis and P. intermedia. Subgingival plaque was sampled in each subject from a single site exhibiting the greatest inflammation. The evaluation of selected periodontal bacterial pathogens was based on an immunoassay utilizing bacterial specific monoclonal antibodies. 35% of the sites harbored P. gingivalis , 28% F. nucleatum and 21% E. corrodens. A. actinomycetemcomitans and P. intermedia were found in less than 10% of the sites. Subjects for whom the probing depth at the sampled site was 4 mm were more often found to have detectable pathogens than those with a probing depth 3 mm. Diabetic factors such as duration, type and metabolic control of the disease had no statistically significant effect on the prevalence of these bacteria.     

The effect of periodontal treatment on metabolic control of type 1 diabetes mellitus

The objective of this investigation was to study the effect of nonsurgical periodontal treatment, with or without systemic administration of doxycycline, on the metabolic control of patients with type 1 diabetes. Sixty type 1 diabetic subjects with moderate to severe periodontitis were recruited. Periodontal parameters were measured, and blood samples were obtained to evaluate glycosylated hemoglobin (HbA1c). Group 1 (30 patients) was treated with scaling, root planning, and chlorhexidine rinses for 3 months in conjunction with systemic administration of doxycycline (100 mg once a day for 15 days). Group 2 (30 patients) received the same periodontal treatment but without the use of doxycycline. The paired Student t-test was used to detect differences between glycosylated hemoglobin means before and 3 months after periodontal treatment in group 1 and group 2 separately. Changes in mean HbA1c after treatment were 0.07% in group 1 and –0.06% in group 2, which were not statistically significant after 3 months. Significant changes were not found even in patients with the best response to periodontal treatment. Periodontal treatment in type 1 diabetic patients after 3 months follow-up did not improve metabolic control of diabetes as measured by glycosylated hemoglobin.

The influence of microvascular complications caused by diabetes mellitus on the inflammatory pathology of periodontal tissues

The aim of our study was to analyze inflammatory pathology of periodontal tissues in patients with diabetes mellitus, and the relationship of this pathology with other complications caused by diabetes mellitus. In our study, we evaluated 126 people aged 16-53 years (42 males and 84 females) with diabetes mellitus admitted to the Clinic of Endocrinology of the Hospital of Kaunas University of Medicine (HKUM). The condition of periodontal tissues was evaluated according to the World Health organization (WHO) CPITN index. Oral hygiene was evaluated using a simplified oral hygiene index (OHI-S) according to Green-Vermillion. Out of 126 subjects with diabetes mellitus, periodontitis was detected in 96 patients (36 males and 60 females) (CPITN index 2-5). Gingivitis was found in 27 subjects (CPITN index 1). Only 2.4% of the studied patients had healthy periodontal tissues. The study analyzed complications of other organs (neuropathy, and nephropathy and retinopathy) caused by diabetes mellitus. The obtained findings showed that microvascular complications were diagnosed more frequently in the presence of more severe inflammatory pathology of periodontal tissues. Retinopathy was diagnosed in patients with CPITN index 2.8+/-0.1, while patients with CPITN index 1.8+/-0.3 had no retinopathy. Neuropathy was more common among patients whose CPITN index was 2.9+/-0.1, while the condition was absent in cases where the CPITN index was 1.8+/-0.2. Comparable results were yielded by the studies of nephropathies in relation with changes in periodontium. Nephropathy was diagnosed in patients whose CPITN index was 3.0+/-0.1, and was not found in patients with CPITN index 2.1+/-0.2. The generalization of the obtained study data allows for stating that a more detailed analysis of factors causing complications of diabetes mellitus will also allow for a more profound understanding of the etiopathogenetic mechanisms that cause inflammatory pathology of periodontal tissues.