ABSTRACT
http://dx.doi.org/10.1590/1678-7757201302106
Periodontal disease and diabetes mellitus
1, Olinda TARZIA2 3 !
1- PhD in Medical Sciences, Research Support Center, Diabetics Association of Bauru, São Paulo, Brazil.
2- PhD in Oral Biochemistry, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
4- DDS, MSc, PhD, Full Professor. Department of Stomatology, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
e-mail: [email protected]
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eriodontal 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.
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
!"#$%"#$#&'* ' + databases, in English and Portuguese languages published from 1960 to October 2012.
Primary research reports on investigations of relationships between DM/DM control, PD/
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 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 control and possibly reduce the burden of diabetes-related complications.
Key words: Periodontal diseases. Diabetes mellitus. Diabetes mellitus, Type 1. Diabetes mellitus, Type 2. Gestational diabetes. Glycemic control. Diabetes complications.
INTRODUCTION
In the last decades health professionals have been often organized into many specialties and subspecialties directed to several body organs and systems. The human organism is a unity that
processes so strongly linked that abnormalities in any part of the body and/or its processes may have
in this review by two highly prevalent diseases: PD and DM25.
PD is a chronic infectious disease, caused by
Gram-negative microorganisms. An imbalance between a localized infection and an exaggerated
in determining gingival tissue damage. Recent evidence suggests that the effect of PD might not be limited just to the oral cavity but it might have systemic consequences. Indeed, PD has also been
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response. Although, the mechanisms behind this association remain unclear, PD might represent one
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This association could explain the increased risk of impaired metabolic control in diabetes-related
complications and the adverse effects of DM on periodontal health15. There is strong evidence that the prevalence, severity and progression of PD are
97,98,101. In this review we describe the common processes involved in PD and DM and briefly review the evidence produced to support an association between PD, DM and diabetes-related complications.
Periodontal disease
PD is a chronic bacterial infection that affects both the gingiva and the bone that supports the teeth and is caused by anaerobic Gram-negative microorganisms that are present in the bacterial plaque that adheres to the teeth69.
PD is a very prevalent condition. In the United States, over half the population aged 18 years or more have PD in its early stages, increasing to up to 75% after the age of 35 years; its mild to moderate forms are present in 30% to 50%, and the severe generalized form in 5% to 15% of the general adult population25. PD has even higher prevalence in minorities, in poor and developing countries and a considerable global variation77,96.
The presence of anaerobic Gram-negative
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of the gingiva causes alveolar bone destruction and loss of the tissue attachment to the teeth, caused by components of microbial plaque that have the
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cells, such as lymphocytes, macrophages, and polymorphonuclear leukocytes (PMNs)93.
Some microbial components, especially lipopolysaccharide (LPS), activate macrophages that synthesize and secrete a great variety and amount of pro-inflammatory molecules, such as the cytokines interleukin-1 (IL-1) and
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especially prostaglandin E2 (PGE2); and some other enzymes93.
Bacterial toxins can also activate T lymphocytes to produce IL-1 and lymphotoxin (LT), a molecule
and catabolic activities, and have important roles in periodontal tissue destruction caused by collagenolytic enzymes such as metalloproteinases (MMPs)93. These collagenolytic enzymes are activated by reactive oxygen species and elevate
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gingival tissue56.
The attachment loss deepens the sulcus, creating a periodontal pocket that contains thousands of millions of bacterial cells. This stage is the transition between gingivitis and periodontitis, the most common PDs26,50.
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disrupted on a regular basis, the emergences of Gram-negative anaerobic bacterial species activate several host processes that will interfere in the extent and severity of the disease25.
Recently, many advances have occurred in the knowledge of the nature of the infectious agents involved in PD. Approximately 500 different bacterial entities and various human viruses have already been associated with the formation of dental microbial plaque3.
The most frequently recognized periodontal pathogens belong to three microaerophilic species (Actinobacillus actinomycetemcomitans, Campylobacter rectus, and Eikenella corrodens) and seven anaerobic species (Porphyromonas gingivalis, Bacteroides forsythus, Treponema denticola, Prevotella intermedia, Fusobacterium nucleatum, Eubacterium, and spirochetes)92. Various herpes viruses, such as the human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV-1), have recently also emerged as pathogens in cases of destructive PD90.
Many conditions can predispose and/or facilitate the occurrence of PD such as smoking7,32,35,105,
< 9,49,62 30,32,35, estrogen excess39, dyslipidemia58,66,111 and obesity2,27. The prevalence of obesity is increasing worldwide. This epidemic is also associated with an increased occurrence of obesity-related diseases like hypertension, cardiovascular disease, metabolic syndrome and DM that are also linked to PD2,27.
Diabetes mellitus
DM encompasses a group of genetically and clinically heterogeneous metabolic disorders characterized by hyperglycemia that results from a defective insulin secretion and/or activity89.
type 1 (T1D), type 2 (T2D), gestational diabetes
the destruction of beta-cells within the islets of Langerhans of the pancreas, which results in a
C 4 mediated or have an idiopathic etiology. T2D ranges from an insulin resistance which progresses into
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recognition during pregnancy. Lastly, the category
several types of DM with different etiologies21. Developed countries have a higher prevalence of DM than developing countries and more women than men are affected with DM. T2D constitutes 90% of the cases. In 1995 the prevalence of DM in adults all over the world was estimated to be around 4.0% and it was expected to rise to 5.4%
by the year 2025. Numerically it means a rise from 135 million in 1995 to 300 million in the year 2025. The majority of this increase will occur in developing countries. An increase of 42% (from 51 to 72 million) is expected in developed countries and an increase of 170% (from 84 to 228 million) in the developing world. Therefore, it is expected that by the year 2025, 75% of people with DM will be living in developing countries where the majority of people with DM are aged between 45-64 years old.
In developed countries, the majority of people with DM are older than 65 years. DM will be increasingly occurring in urban areas47.
People with diabetes and with chronically poor metabolic control can experience micro-vascular and macro-vascular complications leading to a
society. This burden includes direct costs of medical care and indirect costs, such as loss of productivity, which result from diabetes-related morbidity and premature mortality4,38.
Health care expenses for people with diabetes is more than two-times higher than the expenses for people without diabetes; the direct and indirect expenditures attributable to diabetes in 2007 in the USA were estimated at US$174 billion, with slightly more spent on chronic complications attributable to DM than properly on DM care4. The International Diabetes Federation estimated that DM costs account for 5-10% of the total healthcare budget in many countries40.
In Brazil, the per capita total, direct medical, direct nonmedical and indirect costs of patients with T1D were US$ 1,741.42, US$ 1,319.15, US$
61.47 and US$ 360.81, respectively. The total direct non-medical costs were US$ 195,461.54, spent with transportation for the patients and caregivers29. Total annual costs for care of outpatients with T2D were US$ 2,108 per patient, out of which US$ 1,335 per patient of direct costs (63.3%) and US$ 773 per patient of indirect costs (36.7%). Patients with both micro-vascular and macro-vascular complications had higher costs (US$ 3,199 per patient) compared to those with either micro-vascular (US$ 2,062 per patient) or macro-vascular (US$ 2,517 per patient) complications only. The greatest amount of direct costs was attributed to medication (48.2%)6.
Effects of diabetes mellitus on periodontal disease
The search conducted for this review used
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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
33 4
relevant papers and meta-analyses published in this period. This review does not provide an assessment
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following groups: 1- The effects 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.
The studies listed in Figure 1 compared periodontal status in individuals with and without DM in the majority of the reports. These studies
of diabetes, sample number, age range, evaluation of PD and other diabetes-related variables. The majority of the studies were cross-sectional (21/29) and limited in the possibility of providing a causal- effect relationship.
The link between DM and the adverse effects on PD has been extensively described61,96. We have found that 27 in 29 studies showed supportive evidence of the adverse impact of DM on periodontal health.
There were four studies of T1D; one study reported more extensive radiographic bone loss in patients with T1D compared to the controls102, Lalla, et al.54 (2006) in a case-control study found that periodontal destruction can start very early in life in patients with T1D and becomes more prominent as children become adolescents54. In a population aged 4 to 33 years, Cianciola, et al.13
of PD in T1D than in non-diabetic siblings and non- diabetic unrelated controls. The prevalence of PD among 11- to 18-year-old teenagers with DM was 9.8% as compared to 1.7% in controls without DM.
An accelerated periodontal destruction was found in children and teens with DM, with poor metabolic control13. In an adult population aged 40-69 years, 58.4% of patients with long standing T1D exhibited severe PD as opposed to 7.1% of controls without DM103.
Regarding the relationship between T2D and PD,
comprised of patients aged 15 years or older20,70, and twelve8,10,12,13,19,59,60,74,80,100,106,113 included only adults. Twelve of these fourteen studies reported
+ prevalence was found in one study8 and no 113.
Six reports consist of analyses in which subjects with T1D and T2D were analyzed together without distinction of diabetes type. Four studies included children and adolescents6,46,53,85 and another two included only adult subjects17,73. Five of these six studies reported greater prevalence, extent, or severity of PD in subjects with DM 5,17,46,53,85. One
Effects of diabetes mellitus on periodontal disease ReferenceYear = C Diabetes C"
Number of subjects (DM/control) Age FC G
Periodontal evaluationOther diabetes related variables considered Cianciola, et al.131982Cross-sectional1263/2084 to 33Prevalence and severity of PDDiabetes duration Prevalence and severity of PD in T1D is more strongly related to chronological age than diabetes duration Emrich, et al.191991Cross-sectional21,342/1,87715 to >55Probing attachment level, alveolar bone loss, age, sex, calculus index, plaque index, " " #$ %&'(( Diabetes controlT2D increases the risk of PD independently of age, sex, and hygiene or other dental measures Thorstensson, et al.1031993Cross-sectional183/9940 to 69Gingival conditions, probing pocket depth and alveolar bone level
Diabetes durationAge of onset appears to be an important risk factor for PD Shlossman, et al.851990Cross-sectional1 and 2736/2,483)(*+)Probing attachment loss and radiographic bone loss Biennial oral glucose tolerance test Subjects with DM had a higher prevalence of PD; DM may be a risk factor for PD Nelson, et al.701990Longitudinal21,363/910*<)Tooth loss and interproximal crestal alveolar bone loss
- PD in subjects with DM is 2.6 times more prevalente than in non-diabetic controls Taylor, et al.1001998Longitudinal224/36215 to 57Severity of bone loss-DM2 is associated with the incidence of alveolar bone loss and increased rate of alveolar bone loss progression Tervonen, et al.1022000Cross-sectional135/1029Bone lossGlycemic control; duration of diabetes; diabetes severity Increased bone loss in subjects with complicated T1D already at an early age. Sandberg, et al.802000Cross-sectional2102/10264Gingivitis and bone lossGlycemic control; duration of diabetes; diabetes severity
Subjects with T2D in some oral conditions exhibited poorer oral health Taylor GW972001Review1,2 and GDM
-Mixed ages Evaluation of a bidirectional relationship between DM and PD -The majority of the studies provided consistent evidence of a greater prevalence, severity, extent or progression of PD in subjects with DM Orbak, et al.742002Cross-sectional240/2041GingivitisGlycemic control; diabetes complications
T2D and smoking are high-risk factors for PD Tsai, et al.1062002Cross-sectional2502/3,841>45Loss of periodontal attachment Glycemic controlPositive association between poorly controlled T2D and severe PD Zielinski, et al.1132002Cross-sectional232/40>60Pocket depthGlycemic control; duration of diabetes
No differences in oral health were found between subjects with T2D and those in the control group Arrieta-Blanco, et al.52003Cross-sectional1 and 270/7411 to 81Pocket depth; loss of periodontal attachment; bone loss
Glycemic control; duration of diabetes; diabetes severity
The gingivitis index was higher and the treatment was more complex in subjects with DM Endean, et al.202004Cross-sectional2289/1,706<)(*+)Pocket depth; tooth lossNoneThe severity of PD and tooth loss was greater in subjects with DM than in controls Lu and Yang592004Cross-sectional272/9254Gingivitis and loss of periodontal attachment
Glycemic control; duration of diabetes; diabetes severity In subjects with T2D, PD is more severe than in healthy individuals Campus, et al.102005Cross-sectional271/14135 to75Gingivitis and pocket depthGlycemic controlSubjects with T2D have a susceptibility for more severe PD Chuang, et al.122005Cross-sectional243/8528 to 85Pocket depthGlycemic control; end-stage renal disease
Diabetic uremic patients undergoing hemodialysis exhibited a higher risk for dental decay and xerostomia Ogunbodede, et al.732005Cross-sectional1 and 265/5425 to 82Pocket depthDuration of diabetes Oral health of a subject with DM with adequate metabolic control, may not be different from that of a non-diabetic Mattout, et al.602006Cross-sectional271/2,07335 to 75 Gingivitis; pocket depth; loss of periodontal attachment
Fasting blood glucosePD is more severe in subjects with T2D
Figure 1- Effects of diabetes mellitus on periodontal disease K L "
between subjects with and without DM when an adequate metabolic control was found in the former group73.
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One was conducted only with women with GDM that were compared to a control group between the 34-36th gestation weeks. The results of the study suggest that gingivitis seems to be more prevalent in women with GDM compared to healthy pregnant women and the plaque accumulation seems to be
< 65. Another study found that all types of DM increase the risk of PD, including GDM61. Two other studies conducted in the USA collected data from over 4,000 women with a history of GDM. One report included ages 15-44112 and the other, ages 20-59112. Both reports concluded there is a strong relationship between GDM and PD. PD was found in 45% of pregnant women with GDM vs. 13% in the healthy pregnant women, with an adjusted odds ratio of 9.11. In non-pregnant women, 40% of women with T1D or T2D, 25% of those with a history of GDM, and 14%
of healthy women had PD. The odds ratio for those with T1D and T2D was 2.7663. Novak, et al.71 (2006) found the prevalence of PD to be higher in women with a history of GDM and concluded that these women may be at greater risk for developing more severe PD, than women without a history of GDM.
Finally, Taylor96 (2001) and Mealey61 (2006) in two extensive literature reviews found a bidirectional interrelationship between all types of DM, including GDM and PD.
Effects of glycemic control on periodontal disease
Current evidence also supports poorer glycemic control contributing to poorer periodontal health.
V relationship. Two of these studies included subjects with T1D exclusively, seven studies subjects with += with either T1D, T2D, GDM and others (Figure 2).
One prospective study conducted with T1D did not show any association between the degree of glycemic control and PD but a positive association with local oral hygiene measures82, and another study, that was cross-sectional, has regarded this association102. Five of the seven reports published regarding the association between glycemic control and PD in T2D10,43,59,75,106 have found this association and two did not12,80. We
the differences in periodontal health in groups of mixed types of diabetes5,37,45,61,68; three have found this association37,61,68 and two did not5,45. Among these fourteen studies, eleven were cross-sectional that imposes some limitations on the cause-effect inference; two were prospective and one was an
PD= periodontal disease - DM=diabetes mellitus - T1D=diabetes mellitus type 1 - T2D=diabetes mellitus type 2 - GDM=gestational diabetes mellitus
Borges-Yánez, et al.82006Cross-sectional2247/78>60Loss of periodontal attachment Fasting blood glucose?(($H " "J#$(? KQ Xiong, et al.1122006Cross-sectional1, 2 and GDM 256/4,23415 to 44Pocket depth or loss of periodontal attachment Diabetes typePositive association between PD, GDM and pregestational diabetes (T1D and T2D) Novak, et al.712006Cross-sectional2 and GDM
113/4,13120 to 59Gingivitis and pocket depth and loss of periodontal attachment Glycemic control; duration of diabetes Women with GDM may be at greater risk for developing more severe PD than women without GDM Mittas, et al.652006Cross-sectionalGDM64/8828GingivitisNone\ " #$ ' (((J#$ ](] \ Mealey, et al.612006Review1, 2 and GDM
-Mixed ages Relationship between PD and DM - All types of DM increase the risk of PD Jansson, et al.432006Transversal2191/0Mixed ages
PDGlycemic contrrol Subjects with T2D are at increased risk for PD Khader, et al.462006Meta- analysis (1970 to 2003)
1 and 223 studies (total of 19,245) 5 to 78PDSeverity of PD`] % " $H " # H &( PD than nondiabetics Lalla, et al.542006Case-control1182 /1606 to 18Gingivitis Evolution of PD severityPeriodontal destruction can start very early in life in subjects with T1D Lalla, et al.532007Cross-sectional1 and 2350/3506 to 18Gingivitis and pocket depth and loss of periodontal attachment
Glycemic control; duration of diabetes Positive association between T1D and an increased risk for PD even very early in life Demmer, et al.172008Longitudinal1 and 2652/9,296 25 to 74Presence of PD and its severity-PD is an independent predictor of incident DM2
extensive literature review. Otherwise, nine of these reports support the evidence of greater prevalence, extent and severity of PD and also provide evidence that glycemic control worsens in parallel with the worsening of PD.
E f f e c t s o f p e r i o d o n t a l d i s e a s e o n glycemic control and on diabetes-related complications
Substantial evidence has been demonstrating DM as a risk factor for the impairment of periodontal health and a growing body of evidence has been supporting PD as having an adverse effect on glycemic control and on the pathophysiology of diabetes-related complications. The inflamed periodontal tissue may serve as a chronic source of
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been shown to have important effects on lipid and glucose metabolism24,31,36,57 and have also been reported to be insulin antagonists and related to insulin resistance that is predominantly found in T2D and GDM23,36,63,76.
As shown in Figure 3, data interpretation is
and PD and different clinical criteria applied to determine the prevalence, extent, severity of PD, levels of glycemic control and diabetes-related complications; there is also marked heterogeneity in the studies’ designs, conduct, length of follow- up, types of participants, and periodontal treatment protocols61,72,76,96.
Evidence regarding the effects of PD on glycemic control comes from observational and treatment studies (Figure 3). The treatment studies are a set of reports that include ten randomized clinical trials (RCTs), twelve non-RCTs, four meta-analyses, one literature review, one longitudinal study, one
transversal study, one retrospective study, one prospective study and two clinical cases discussions.
The RCTs used control groups that were either treated controls, non-treated controls or controls that did not change their usual dental care. Among
'+ periodontal therapy33,34,44,48,51,52,79,88 and two did not1. One of the RCTs, recently conducted, showed &\
< Q 4 CRP, d-8-iso, MMP-2 and MMP-952.
An important source of variation in the RCTs is the use of antibiotics with the non-surgical periodontal therapy. This fact brings a lot of confusion in the interpretation of the results of these trials in such a way, that to date, there is no clear evidence to support a requirement for the use of antibiotics in combination with non-surgical periodontal treatment in order to observe an improvement in glycemic control associated with periodontal therapy98.
Among the group of twenty-three periodontal treatment studies that were not RCTs, seventeen r e p o r t e d a b e n e f i c i a l e f f e c t o n g l y c e m i c control14,16,17,22,41-43,55,64,83,84,87,94,99,101,109,110 and six did not11,78,91,95,108. Only ten of these studies had controls or comparison groups11,14,22,43,78,84,94,99,101,108. Like the RCTs, there was marked variation in the use of adjunctive antibiotics, with six of the eight studies that used systemic antibiotics reporting a
41,42,64,83,87,109. Additional evidence to support the effect of severe periodontitis on increased risk for poorer glycemic control comes from two longitudinal observational studies. A longitudinal epidemiological study of the Pima Indians in Arizona, USA, which present the world’s highest reported prevalence of
Reference Year = C & ( C" Age group " Effect
Sastrowijoto, et al.82 1990 Prospective 1 Adults No No
Tervonen, et al.102 2000 Cross-sectional 1 Adults Yes Yes
Sandberg, et al.80 2000 Cross-sectional 2 Adults Yes No
Tsai, et al.106 2002 Cross-sectional 2 Adults Yes Yes
Arrieta-Blanco, et al.5 2003 Cross-sectional 1 and 2 Mixed ages Yes No
Guzman, et al.37 2003 Cross-sectional 1 and 2 Adults No Yes
Karikoski and Murtomaa45
2003 Prospective 1, 2 and others Adults No No
Lu and Yang59 2004 Cross-sectional 2 Adults Yes Yes
Negishi, et al.68 2004 Cross-sectional 1 and 2 Adults No Yes
Campus, et al.10 2005 Cross-sectional 2 Adults Yes Yes
Chuang, et al.12 2005 Cross-sectional 2 Adults No No
Peck, et al.75 2006 Cross-sectional 2 Adults No Yes
Jansson, et al.43 2006 Cross-sectional 2 Adults No Yes
Mealey, et al.61 2006 Review 1,2 and GDM Mixed ages Yes/No Yes Figure 2- Effects of glycemic control on periodontal disease (GDM= gestational diabetes mellitus)
Effects of diabetes mellitus on periodontal disease ReferenceYear= C designDiabetes C" Subjects & U Age FC G= C duration Periodontal treatment "Metabolic controlEffects on metabolic control and on diabetes-related complications Williams and Mahan.1091960Clinical cases-9/020 - 323 - 7 mExtractions; scaling and probing; gingivectomy; systemic antibioticsNo control groupInsulin requirement; diabetes control
{ |` % " % ( insulin requirements Wolf J1101977Non-RCT1 and 2117/016 - 608 - 12 mScaling; home care instructions on oral hygiene; periodontal surgery; extractions; endodontic treatment; restaurations; denture replacement or repair
No control groupBlood glucose levels; 24 hour glycosuria; insulin dose
K (J (%($ ' ( and periapical lesions does little to improve diabetes control Miller, et al.641992Non-RCT110/0Unknown8 wkScaling; systemic doxycycline No control groupHbA1c; glycated albuminDecrease in HbA1c and glycated albumin in J ] J(#%" " #$ ' (~ patients with no improvement in gingival ' ( % ( "( in HbA1c after treatment Seppala, et al.841994Non-RCT138 (1 year); 22 (2 years) **35 - 561 - 2 yScaling; surgery and extractionNo control groupHbA1c; blood glucose levelsImprovement of HbA1c levels in poorly controlled and in well controlled T1D Aldrige, et al.11995 (Study 1)
RCT116/1516 - 402 mOral hygiene instructions; scalingNo treatment HbA1c; fructosaminePeriodontal treatment showed no effect on improving HbA1c Aldrige, et al.11995 (Study 2) RCT112/1020 - 602 mOral hygiene instructions; scaling; extractions and root canal therapyNo treatment HbA1cPeriodontal treatment showed no effect on improving HbA1c Grossi, et al.341996RCT289/2425 - 6512 mUltrasonic bactericidal curettage with irrigation using either water, chlorhexidine or polvidone-iodine with or without systemic doxycycline
Ultrasonic curettage with irrigation using water and placebo
HbA1cThe thrre groups receiving doxycycline and ultrasonic bacterial curettage showed " % ( < three months Smith, et al.911996Non-RCT118/026 - 572 mScaling; oral hygiene instructionsNo control groupHbA1cPeriodontal treatment showed no statistically " ( J(# " < Westfelt, et al.1081996Non-RCT1 and 220/2045 - 655 yOral hygiene instructions; scaling; periodic prophylaxy; surgery at sites with bleeding on probing; periodontal pocket depth > 5 mm
Same treatment as subjects with T1DHbA1cThe mean value of glycated HbA1c between $ $$Q+( ]( " $H different from that between 24-60 months Taylor, et al.991996Prospective cohort249 and 56 subjects with severe and lees severe periodontitis and no treatment
18 - 672 - 4 yNot applicableNo control groupHbA1cSubjects with severe periodontitis were about 6 times more likely to have poor glycemic control at follow-up Grossi, et al.331997RCT289/2425 - 656 mPeriodontal treatment included ultrasonic scaling and curettage combined with one of four different antimicrobial regimens No treatment Serum glucose levels; HbA1cEffective treatment of periodontal infection %% ((J (%($ ' ( associated with a reduction in levels of HbA1c Christgau, et al.111998Non-RCT1 and 220/2030 - 662 mScaling; subgingival irrigations with chlorhexidine; oral hygiene instructions; extractions
Same treatment as subjects with DMHbA1cNo effect on HbA1c Collin, et al.141998Retrospective cohort225/40 - no subjects received treatment 58 - 772 - 3 yNot applicableNo treatment HbA1cIn subjects with T2D the HbA1c levels are " $H % (] %#% periodontitis Iwamoto, et al.412001Non-RCT213/ 019 - 651 mLocal minocycline in every periodontal pocket and mechanical debridment once a week for a month
No control groupHbA1cAnti-infectious treatment is effective in improving metabolic control Stewart, et al.942001Non-RCT236/3662 - 6718 mScaling; subgingival curettage and root planing; oral hygiene instructionsNo treatment HbA1c; changes in medications dosesPeriodontal theraphy was associated with improved glycemic control K L "
Figure 3- Effects of periodontal disease on glycemic control and diabetes-related complications
Abbreviations: RCT, randomized controlled trial; Non-RCT, non-randomized controlled trial-treatment study; D, days; Wk, weeks; M, months; Y, years; HbA1c, glycated hemoglobin - PD= periodontal disease - DM=diabetes mellitus - T1D=diabetes mellitus type 1 - T2D=diabetes mellitus type 2 - GDM=gestational diabetes mellitus
Rodrigues, et al.792003RCT215/15Unknown3 mScaling; systemic amoxicillin/ clavulanic acid; oral hygiene instructions at baseline and every two w Same as treatment group, except no medication HbA1c and fasting plasma glucosePeriodontal therapy was associated with improved glycemic control in treatment group Skaleric, et al.882004RCT110/1026 - 5824 wkScaling and minocycline (J J(*) baseline and at 12 w
ScalingHbA1cDecreased HbA1c in test and control groups; ] (H$ " $H more effective than sacaling alone Kiran, et al.482005RCT222/2231 - 793 mScaling; oral hygiene instructions No treatment HbA1c; fasting and 2-h post-prandial glucose levels
Decreased HbA1c and 2-h post-prandial glucose levels in treatment group Promsudthi, et al.782005Non-RCT227/2555 - 80 3 mMechanical periodontal treatment and systemic doxycycline for 15 dNo treatment HbA1c and fasting plasma glucoseNo association between periodontal treatment with adjunctive antimicrobial treatment and changes in HbA1c levels Janket, et al.422005Meta- analysis1 and 2456Mixed ages25 yScaling; antibioticNo treatment HbA1cDecrease in HbA1c of 0,66% in those patients with type 2 diabetes without antibiotic use, and of 0,71% in those that used antibiotics Talbert, et al.952006Non-RCT225/016 - 643 mScalingNo control groupHbA1c; fasting glucose levels and fasting plasma insulin
Treatment did not decrease the levels of HbA1c Schara, et al.832006Non-RCT110/03812 mScaling and local chlorhexidine No treatment HbA1cDecrease in HbA1c after three months of treatment, but no decrease 6 months after the end of the study Faria-Almeida, et al.222006Non-RCT210/1035-706 mScalingScalingHbA1c " % <$#$ Jansson, et al.432006Transversal238/153552yNo treatmentNo control groupHbA1cThe best predictor for severe PD in subjects with T2D is smoking followed by HbA1c levels; T2D subjects are at increased risk for PD Jones, et al.442007RCT282/83594 mScaling; doxycycline 100 mg daily for 14 days; chlorhexidine 30 ml during 4 m
Usual careHbA1c; insulin usePeriodontal and systemic therapies improved glycemic control Demmer, et al.172008Longitudinal29,29625 - 7420 yNo treatment No control group-Subjects with PD showed a two-fold increase in the chance of having DM; patients with advanced PD show greater risk for T2D Darré, et al.162008Meta- analysis1 and 29 studies (485)Mixed ages-Periodontal treatment No treatment HbA1c " % <$#$ Lamster, et al.552008Review1 and 2-Mixed ages6 y-No treatment -37/44 cross-sectional studies and 7/7 prospective studies showed a realtionship between DM and PD Teeuw, et al.1012010Meta- analysis25 studies (199/183)Mixed ages3 - 9 mPeriodontal treatment No treatment HbA1c " #"%(+ HbA1c levels; the most important reductions in HbA1c levels were observed in two studies that did not use antibiotics Simpson, et al.872011Meta- analysis1 and 2-18-80-Periodontal treatment with and without antibiotics; oral hygiene instructions No treatment HbA1cImprovement in glycemic control after periodontal treatment Koromantzos, et al.512011RCT230/3040 - 756 mOral hygiene instructions; non- surgical periodontal treatment every 7 d
Ultrasound prophylaxyHbA1c " % <$#$ treatment group Koromantzos, et al.522012RCT230/3040 - 756 mOral hygiene instructions; non- surgical periodontal tretment every 7 d Ultrasound prophylaxyHbA1cEffective non-surgical periodontal treatment of subjects with T2D and moderate to severe PD J(#% " $H <$#$% %( $ $$H " J(# $#$( '(H
DM16, found that subjects with T2D in good to moderate control and with severe periodontitis at baseline were approximately six times more likely to have poor glycemic control at a 2-year follow-up than those without severe periodontitis at baseline96. Collin, et al.14 (1998) in another observational study of 25 adults with T2D, aged 58-77 years, also reported an association between advanced periodontal disease and impaired metabolic control14.
Recently, some important trials have recognized that poor glycemic control is a major determinant for the development of the chronic complications of DM. The Diabetes Control and Complications Trial, the Epidemiology of Diabetes Interventions and Complications (EDIC) Trial, the long-term follow-up study of the DCCT, both conducted with T1D and the United Kingdom Prospective Diabetes Study (UKPDS) conducted with T2D, demonstrated that attaining and maintaining good glycemic control could reduce the risk for and/or postpone the progression of micro-vascular complications in patients with T1D and T2D18,67,107.
Initially, the UKPDS observed a statistically non- \ 8! Q combined fatal or nonfatal myocardial infarction and sudden death. Recently, it was observed that a long-
long-term consequences including the reduction in the risks of fatal or nonfatal myocardial infarction and sudden death. The epidemiological analysis from the UKPDS showed a continuous association between the risk of cardiovascular complications and glycemic control; every percentage point decrease in HbA1c, was associated with a 25%
reduction in diabetes-related deaths, 7% reduction in all-cause mortality, and a 18% reduction in combined fatal and nonfatal myocardial infarction28.
Some observational studies regarding the association between PD and the risk for DM complications have given strong evidence for this association. In a study conducted in Sweden, with 39 case-control pairs of individuals with T1D and T2D for a median follow-up time of six years, Thorstensson, et al.104 (1996) observed
and cardiovascular complications such as stroke, transient ischemic attacks, angina, myocardial infarction and intermittent claudication in the case
8 +
that an association between renal disease, cardiovascular disease and its complications and severe periodontitis seems to exist104.
Saremi, et al.80 (2005), studied the contribution of PD to the mortality associated with T2D in the Gila River Indian Community in Arizona, USA, on behalf of the National Institute of Diabetes and Digestive and Kidney Diseases, addressing
nephropathy and cardiovascular disease. This was a prospective longitudinal study with a cohort of 628 individuals, aged approximately 35 years old, for a median follow-up of eleven years (range 0.3 to 16). During the study period 204 subjects died.
Individuals with severe PD had 3.2 times greater risk for cardio-renal mortality (i.e., ischemic heart disease and diabetic nephropathy combined) compared with the reference group (no, mild, or moderate PD combined), after adjustment for several major risk factors of cardio-renal mortality such as age, sex, diabetes duration, HbA1c, body mass index (BMI), hypertension, blood glucose, cholesterol, electrocardiographic abnormalities, macro-albuminuria, and smoking81.
Another study conducted by Shultis, et al.86 (2007), in the same community investigated the effect of periodontitis on overt nephropathy and end-stage renal disease (ESRD) in a group of 529 subjects with T2D, aged approximately 25 years old. After adjusting for age, sex, diabetes duration, BMI, and smoking, they found that
associated with the risk of overt nephropathy and ESRD. The incidence of macro-albuminuria was 2.0, 2.1, and 2.6 times greater in individuals with moderate or severe periodontitis or in those who were edentulous, respectively, than those with none/mild periodontitis. The incidence of ESRD was also 2.3, 3.5, and 4.9 times greater for individuals with moderate or severe periodontitis or for those who were edentulous, respectively, than those with none/mild periodontitis86.
Summary and conclusions
The clinical and epidemiological evidence found in the literature we reviewed provides support for the concept that DM can have adverse effects on PD, that PD worsens in parallel with glycemic control
in the risk for diabetes-related complications.
However, further prospective, rigorous, controlled trials with a larger number of patients, in ethnically diverse populations are warranted to establish these relationships and that treating PD can positively
<
burden of diabetes-related complications.
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