Adherence to mediterranean diet, physical activity level and severity of periodontitis. Results from a University-based cross-sectional study

Treatment of periodontitis ameliorates the severity and extent of psoriasis-A randomized clinical trial

AIM

To assess the impact of non-surgical periodontitis treatment over conventional dermatological treatment on the severity and extent of psoriasis in patients affected by comorbid psoriasis and periodontitis.

METHODS

Seventy-four patients affected by both psoriasis and Stages I-IV periodontitis were randomized to receive either Steps 1-2 (non-surgical) of periodontal therapy (test group; n = 37) or no treatment (control group; n = 37). The two groups were balanced in terms of psoriasis medications, with the majority of the included patients undergoing biologics (74.0%) as monotherapy, while minor proportions were under systemic medications (13.7%) or none/topical/phototherapy (12.3%). The psoriasis area severity index (PASI) was regarded as the primary outcome. The body surface area (BSA) and the dermatology life quality index (DLQI) were additionally considered as dermatological outcomes. Probing pocket depth, recession depth, clinical attachment level periodontal inflamed surface area, and [full mouth plaque score] etc, periodontal inflamed surface area, and full-mouth plaque and bleeding scores (FMPS/FMBS) were also measured.

RESULTS

Periodontal therapy in the test group led to statistically significant lower PASI scores at 10 weeks (mean = 3.15; standard deviation [SD] = 3.78) compared to the control group (mean = 7.11; SD = 6.09) (mean difference [MD] = -4.0; 95% confidence interval [CI]: -6.3, -1.6; p = .001). The test group also showed improvements in BSA (MD = -4.3) and periodontal parameters compared to the control group. DLQI only showed a non-statistically significant tendency (MD = -2.0).

CONCLUSION

Steps 1-2 of periodontal therapy showed an additional effect over conventional dermatological treatment in reducing the severity and extent of psoriasis (Clinicaltrials.gov: NCT05311501).

Mediterranean diet: a potential player in the link between oral microbiome and oral diseases

Background

The oral microbiome is a complex and dynamic assemblage of microorganisms that colonize different sites of the oral cavity maintaining both oral and systemic health. Therefore, when its composition is altered, oral diseases occur. Among oral inflammatory pathologies, periodontal diseases affect the tissues surrounding the teeth, representing the main cause of tooth loss and one of the most important threats to the oral health. Lifestyle and eating habits influence the composition of the human oral microbiota and the development and progression of oral diseases. In this context, the Mediterranean Diet (MD) model, comprising both healthy dietary choices and lifestyle, is linked to the prevention of several metabolic and chronic-degenerative pathological processes, including oral diseases. Indeed, the MD is a plant-based diet, enriched of anti-inflammatory and antioxidant nutrients, which may induce beneficial effects against dental caries and periodontal diseases.

Aim

This review summarizes the role of the oral microbiome in the development of the oral diseases and the potential of MD in modulating the oral microbiome leading to implications for oral health.

Conclusions

The data collected highlight the need to promote the MD pattern along with the correct hygiene habits to prevent the development of oral diseases.

Association between Mediterranean diet and periodontitis among US adults: The mediating roles of obesity indicators

OBJECTIVE

This study aimed to assess the association between the Mediterranean diet (MedDiet) and periodontitis in US adults and to further explore the mediating roles of obesity indicators in this association.

BACKGROUND DATA

The relationship between MedDiet and periodontitis is controversial. And it is unclear whether obesity indicators are potential mediators of this relationship.

METHODS

Using data derived from the National Health and Nutrition Examination Survey (2009-2014). Weighted binary logistic regression and restricted cubic spline were used to assess the association between MedDiet and periodontitis. Weighted ordinal logistic regression was performed to evaluate the relationship between MedDiet and periodontitis severity. The mediating roles of body mass index (BMI) and waist circumference in the relationship between the MedDiet and periodontitis were explored. Association analyses were further performed using mean clinical attachment loss (CAL) or mean periodontal probing depth (PPD) as dependent variables. The false discovery rate method was used to correct the p-values in the regression analyses.

RESULTS

A total of 8290 eligible participants (4159 participants with periodontitis and 4131 without periodontitis) were included. A negative association between the MedDiet adherence score and periodontitis was observed in the binary logistic regression model (adjusted odds ratio = 0.94, 95% confidence interval: 0.90-0.97, p = .001). Restricted cubic spline regression revealed a dose-response relationship between the MedDiet adherence score and periodontitis. BMI and waist circumference significantly mediate this association, with mediation proportions of 9.7% (p = .032) and 9.3% (p = .012), respectively. Multivariable ordinal logistic regression showed that the MedDiet adherence score was negatively associated with the severity of periodontitis (all p < .05). Additionally, the MedDiet adherence score was negatively associated with mean PPD or mean CAL (all p < .05).

CONCLUSIONS

This study suggests a significant negative association between adherence to the MedDiet and periodontitis and a possible mediating role of obesity indicators in this association. Furthermore, studies are still warranted to confirm our findings.

Multiplicative effect of stress and poor sleep quality on periodontitis: A university-based cross-sectional study

BACKGROUND

The aim of this study was to evaluate the association of perceived stress and poor sleep quality with periodontitis in a university-based cohort of individuals.

METHODS

A total of 235 individuals were included in this cross-sectional study. Perceived stress and sleep quality were evaluated through validated questionnaires, while periodontitis was identified with a full-mouth periodontal examination protocol using both European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) and Centers for Disease Control and Prevention (CDC)/AAP case definitions. Simple and multiple linear and ordinal logistic regression analyses were performed to evaluate the association between perceived stress and sleep quality with periodontitis prevalence and severity.

RESULTS

Stage III/IV periodontitis resulted associated with both moderate/high perceived stress (odds ratio [OR] = 5.4; 95% confidence interval [CI]: 2.2-13.5; p < 0.001) and poor sleep quality (OR = 3.0; 95% CI: 1.2-7.4; p < 0.05). The interaction between moderate/high perceived stress and poor sleep quality presented a multiplicative association with stage III/IV periodontitis (EFP/AAP; OR = 5.8; 95% CI: 1.6-21.3; p < 0.001). Multiple linear regression analyses indicated a similar trend of association also with linear periodontal parameters, that is, mean clinical attachment level (CAL) and mean probing pocket depth (PPD).

CONCLUSIONS

The findings from the present study suggest that stress and poor sleep quality may exert a multiplicative effect on periodontitis prevalence and severity.

Impact of dietary inflammatory index on gingival health

BACKGROUND

Periodontal disease is a biofilm-dependent chronic inflammatory condition triggered by a host response. Several factors impact systemic inflammation and could lead to changes in disease pathogenesis. Recently, studies have assessed the influence of nutritional patterns on the development of periodontitis. In the present cross-sectional study, we evaluated the dietary inflammatory profile on periodontal conditions, focusing on clinical, subgingival microbial, and cytokine assessment of individuals with periodontal health or gingivitis.

METHODS

One hundred patients with periodontal health or gingivitis were included. Plaque index (PI), Bleeding on probing (BoP), the probing depth (PD), and the clinical attachment level (CAL) for each patient were assessed. Nutritional data and the Dietary Inflammatory Index (DII) were recorded by two 24-h food recalls on non-consecutive days. Biofilm and gingival crevicular fluid (GCF) to assess the microbiome profile and inflammatory biomarkers were collected. Multiple regressions focused on the DII, age, and sex as predictors of periodontal conditions were done.

RESULTS

Age and moderate DII scores increased the risk of gingivitis by 1.64 and 3.94 times, respectively. Males with an elevated DII score had 27.15 times higher odds of being diagnosed with gingivitis and BoP (β = 6.54; p = 0.03). Elderly patients with a moderate or high DII score were less prone to gingivitis and increased BoP (p < 0.04) compared with younger subjects. Considering the DII, there were no differences in microbial alpha and beta diversity; however, distinct species abundance and a higher concentration of monocyte-chemoattractant protein-1 and interleukin 33 were seen in patients with a higher DII.

CONCLUSION

A pro-inflammatory diet significantly contributes to periodontal inflammation, modulating inflammatory biomarkers and affecting the subgingival microbial community in healthy individuals.

The underlying relationship between exercise and the prevalence of periodontitis: a systematic review and meta-analysis

BACKGROUND

Although exercise has been proposed as an effective intervention for various lifestyle-related diseases and pathological scenarios, few researches assessed the impact of taking exercise on the prevalence of periodontitis.

PURPOSE

This study aimed to perform a comprehensive literature review and meta-analysis from both observational and intervention studies to explore the relationship between exercise and periodontitis and to provide references for future intervention programs aimed at preventing periodontitis.

METHOD

A systematic literature search was conducted in PubMed/MEDLINE, Web of Science, Cochrane Library, and Scopus for peer-reviewed studies published in English From January 1993 to January 2023 according to the PRISMA guidelines. Articles were selected if subjects were human and studies evaluating the association between exercise and periodontitis.

RESULTS

4098 references were retrieved. After screening the results, 30 studies were selected. Of these, 20 studies indicated an inverse association between exercise and periodontitis, while the remaining 10 did not reach conclusive findings. The meta-analysis demonstrated a risk ratio of 0.84 (95%CI: 0.77, 0.91) between the active group and the inactive group (P < 0.01), which indicated an inverse relationship between exercise and periodontitis.

CONCLUSION

Overall, the increase in exercise presents an inverse association with the presence and severity of periodontitis. Accordingly, taking exercise might be a potential approach that contributes to improvements in periodontitis.

Physical activity as a modifiable risk factor for periodontal disease

Non-communicable diseases (NCDs), which contribute significantly to global morbidity, are largely preventable through behavioral changes. As with other NCDs, periodontitis is associated with modifiable risk factors such as smoking and stress and is linked to multiple adverse health outcomes through a shared pathway of chronic systemic inflammation. While the health benefits of physical activity have been widely promoted in public health and extensively studied for other systemic conditions, its impact on periodontal health has only recently started to gain attention. This article critically evaluates the current literature on the relationship between physical activity and periodontitis. While cross-sectional studies have shown an inverse association between physical activity levels and periodontitis risk in the general population, clinical oral health surveys of elite athletes with high levels of physical activity have nonetheless revealed poor periodontal conditions. Although causality has not been determined, physical activity could positively impact periodontitis directly, by reducing inflammatory biomarkers, and indirectly, through its modulatory effects on insulin sensitivity, obesity, bone density, stress, and other health promoting behaviors. Given the importance of risk factor control during initial periodontal therapy, understanding the role of physical activity as a potential behavioral risk modifier is paramount. The findings of this review provide an evidence-based overview of how physical activity could influence periodontitis. There is a need for longitudinal cohort studies to verify the temporality of the reported associations and exclude confounders, while interventions are needed to assess the efficacy of physical activity on periodontal treatment outcomes.

The association of work physical activity and recreational physical activity with periodontitis in the NHANES (2009-2014)

BACKGROUND

The aim of this study was to investigate the association between different types and intensity of physical activities (PA) and periodontitis in a nationally representative sample of adults in the United States.

METHODS

The data of periodontal condition and PA of 10,714 individuals were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014 and the Global Physical Activity Questionnaire (GPAQ). The association between the prevalence of periodontitis and two PAs (work PA and recreational PA) was respectively analyzed and adjusted by uni- and multi-variable logistic regression models. The odd ratios (ORs), adjusted odd ratios (ORad ), and 95% confidence interval (95% CI) were calculated as the main outcome indicators.

RESULTS

After adjusted by age, sex, race, poverty-income ratio (PIR), diabetes, smoking status, alcohol use, and floss frequency, moderate and vigorous work PAs were significantly correlated with higher odds of periodontitis (ORad  = 1.22, 95% CI = 1.02-1.46; ORad  = 1.40, 95% CI = 1.04-1.89, respectively) while moderate and vigorous recreational PAs were correlated with lower odds of periodontitis (ORad  = 0.81, 95% CI = 0.69-0.95; ORad  = 0.55, 95% CI = 0.43-0.71, respectively).

CONCLUSIONS

Work PAs and recreational PAs have opposite associations on the prevalence of developing periodontitis and their aggravating or protective associations enhance with the increase of intensity.

Immunometabolic capacities of nutritional fatty acids in regulation of inflammatory bone cell interaction and systemic impact of periodontal infection

Introduction

Novel preventive strategies in periodontal disease target the bacterial-induced inflammatory host response to reduce associated tissue destruction. Strategies focus on the modulation of tissue-destroying inflammatory host response, particularly the reduction of inflammation and promotion of resolution. Thereby, nutrition is a potent immunometabolic non-pharmacological intervention. Human studies have demonstrated the benefit of olive oil-containing Mediterranean-style diets (MDs), the main component of which being mono-unsaturated fatty acid (FA) oleic acid (OA (C18:1)). Hence, nutritional OA strengthened the microarchitecture of alveolar trabecular bone and increased circulating pro-resolving lipid mediators following bacterial inoculation with periodontal pathogen Porphyromonas gingivalis, contrary to saturated FA palmitic acid (PA (C16:0)), which is abundant in Western-style diets. Additionally, the generalized distribution of inflammatory pathway mediators can occur in response to bacterial infection and compromise systemic tissue metabolism and bone homeostasis distant from the side of infection. Whether specific FA-enriched nutrition and periodontal inoculation are factors in systemic pathology that can be immune-modulatory targeted through dietary substitution is unknown and of clinical relevance.

Methods

Normal-weight C57BL/6-mice received OA-or PA-enriched diets (PA-ED, OA-ED, PA/OA-ED) or a normal-standard diet (n=12/group) for 16 weeks and were orally infected with P. gingivalis/placebo to induce periodontal disease. Using histomorphometry and LC-MS/MS, systemic bone morphology, incorporated immunometabolic FA-species, serological markers of bone metabolism, and stress response were determined in addition to bone cell inflammation and interaction in vitro.

Results

In contrast to OA-ED, PA-ED reduced systemic bone microarchitecture paralleled by increased lipotoxic PA-containing metabolite accumulation in bone. Substitution with OA reversed the bone-destructive impact of PA, which was accompanied by reduced diacylglycerols (DAG) and saturated ceramide levels. Further, PA-associated reduction in mineralization activity and concomitant pro-inflammatory activation of primary osteoblasts were diminished in cultures where PA was replaced with OA, which impacted cellular interaction with osteoclasts. Additionally, PA-ED increased osteoclast numbers in femurs in response to oral P. gingivalis infection, whereas OA-ED reduced osteoclast occurrence, which was paralleled by serologically increased levels of the stress-reducing lipokine PI(18:1/18:1).

Conclusion

OA substitution reverses the bone-destructive and pro-inflammatory effects of PA and eliminates incorporated lipotoxic PA metabolites. This supports Mediterranean-style OA-based diets as a preventive intervention to target the accumulation of PA-associated lipotoxic metabolites and thereby supports systemic bone tissue resilience after oral bacterial P. gingivalis infection.

Healthy lifestyles are associated with a better response to periodontal therapy: A prospective cohort study

AIM

To evaluate the association between lifestyle behaviours and clinical periodontal outcomes following Steps 1/2 of periodontal therapy.

METHODS

A total of 120 subjects with untreated Stage II/III periodontitis participated in this study. At baseline, questionnaires were administered to assess the following lifestyle behaviours: adherence to Mediterranean diet (MD), physical activity (PA) and stress levels, sleep quality, smoking and alcohol use. Participants received Steps 1/2 of periodontal therapy and were re-evaluated after 3 months. A composite outcome of the endpoint of therapy (i.e., no sites with probing pocket depth [PPD] ≥4 mm with bleeding on probing, and no sites with PPD ≥ 6 mm) was regarded as the primary outcome. Simple and multiple regression analyses were used to evaluate the association between lifestyle behaviours and clinical periodontal outcomes. Disease severity at baseline, body mass index, diabetes, household disposable income and plaque control were considered as confounders.

RESULTS

Multiple regression analyses showed significantly lower odds of achieving the endpoint of therapy in subjects with poor sleep quality (odds ratio [OR] = 0.13; 95% confidence interval [CI]: 0.03-0.47; p < .01), smoking (OR = 0.18; 95% CI: 0.06-0.52; p < .05) and alcohol use above the suggested intake (OR = 0.21; 95% CI: 0.07-0.63; p < .01). Subjects with a combination of 'unhealthy lifestyles' (low adherence to MD and low PA levels and high levels of stress and poor sleep quality) showed higher proportions of residual PPD≥6 mm (MD = 1.51; 95% CI: 0.23-2.80; p < .05) and lower odds of achieving the endpoint of therapy (OR = 0.85; 95% CI: 0.33-0.99; p < .05) at re-evaluation.

CONCLUSIONS

Subjects with unhealthy lifestyle behaviours showed worse clinical outcomes 3 months after Steps 1/2 of periodontal therapy.

Association between the Mediterranean Diet Index and self-reported Gingival Health Status Indicators in a population of Chilean adults: a cross-sectional study

BACKGROUND

Despite the recognized impact of diet on non-communicable diseases, the association between the Mediterranean diet and periodontal diseases is still uncertain. This study aimed to determine the association between adherence to the Mediterranean Diet Index (MDI) and self-reported gingival health status in Chilean adults, exploring the feasibility of using validated web-based survey questionnaires.

METHODOLOGY

Cross-sectional data were collected from a representative sample of a population of Chilean adults (18-60 years old) using a low-cost and time-saving methodology. By the PsyToolkit platform, anonymous survey data were downloaded and analyzed in bivariate (crude) and backward stepwise selection multivariate logistic regression models adjusted for sociodemographic determinants, smoking, and dental attendance using STATA 17. Odds ratios (OR) [95% confidence intervals] were estimated.

RESULTS

In total, 351 complete statistical data were mostly obtained from female university students who had never smoked and reported having visited a dentist in the previous year. Multivariate regression models showed an association between MDI and very good/good gingival health status (OR 1.18 [95% CI 1.04-1.34], p=0.013), absence of bleeding on toothbrushing (OR 1.12 [95% CI 1.01-1.25], p=0.035), and absence of clinical signs of gingival inflammation (OR 1.24 [95% CI 1.10-1.40], p<0.001), after controlling for age, sex, educational level, smoking, and dental attendance.

CONCLUSIONS

We associated adherence to the Mediterranean diet with better self-reported gingival health status in a population of Chilean adults in an entirely web-based research environment. Longitudinal studies with random sampling are required to establish the effect of diet on gingival and periodontal health. Nevertheless, this evidence could contribute to the design of low-cost surveillance programs to reduce the burden of periodontal disease and related "common risk factors".

Effect of psychosocial stress and coping strategies on non-surgical periodontal therapy in patients with generalized stage III/IV periodontitis: a longitudinal intervention study

OBJECTIVES

The aim of this longitudinal intervention study was to assess the impact of psychosocial stress and coping response strategies on the clinical outcomes in periodontitis patients treated with non-surgical periodontal therapy (NSPT).

MATERIALS AND METHODS

After the administration of psychological questionnaires, patients diagnosed with generalized stage III-IV periodontitis were categorized into different groups depending on their stress levels (10-item perceived stress level (PSS-10)) and coping response strategies (coping responses inventory (CRI)). Clinical data were collected 1 week before and 3 months after the completion of NSPT.

RESULTS

Of the 90 patients included at baseline, 27 presented major and 63 minor stress levels, while 40 had avoidance and 50 approach coping behavior. All clinical parameters were similar at the baseline across different categories. At re-evaluation, full-mouth bleeding score (FMBS), mean probing pocket depth (PPD), and number of residual pathological pockets were significantly superior in groups with higher stress levels (p <0.001, p =0.001, and p =0.020, respectively), while higher full-mouth plaque scores (FMPS) and FMBS were found in patients with avoidance coping strategies (p =0.009 and p <0.001, respectively). When jointly evaluated, an added detrimental effect of coping styles on allostatic load was observed. Multivariate analysis confirmed a significant effect of stress levels and coping strategies on final FMBS, but not of coping on mean PPD.

CONCLUSION

Psychosocial stress and avoidance coping strategy seem to negatively influence the clinical outcomes of NSPT at short term (NCT04739475; 9/1/2017).

PRACTICAL IMPLICATIONS

Based on these findings, patients reflecting these psychological profiles should be considered at greater risk for poor NSPT response and may benefit from complementary stress management strategies.

Mediterranean diet component oleic acid increases protective lipid mediators and improves trabecular bone in a Porphyromonas gingivalis inoculation model

AIM

Therapeutic modulation of bacterial-induced inflammatory host response is being investigated in gingival inflammation and periodontal disease pathology. Therefore, dietary intake of the monounsaturated fatty acid (FA) oleic acid (OA (C18:1)), which is the main component of Mediterranean-style diets, and saturated FA palmitic acid (PA (C16:0)), which is a component of Western-style diets, was investigated for their modifying potential in an oral inoculation model of Porphyromonas gingivalis.

MATERIALS AND METHODS

Normal-weight C57BL/6-mice received OA- or PA-enriched diets (PA-ED, OA-ED, PA/OA-ED) or normal standard diet for 16 weeks and were inoculated with P. gingivalis/placebo (n = 12/group). Gingival inflammation, alveolar bone structure, circulating lipid mediators, and in vitro cellular response were determined.

RESULTS

FA treatment of P. gingivalis-lipopolysaccharide-incubated gingival fibroblasts (GFbs) modified inflammatory activation, which only PA exacerbated with concomitant TNF-α stimulation. Mice exhibited no signs of acute inflammation in gingiva or serum and no inoculation- or nutrition-associated changes of the crestal alveolar bone. However, following P. gingivalis inoculation, OA-ED improved oral trabecular bone micro-architecture and enhanced circulating pro-resolving mediators resolvin D4 (RvD4) and 4-hydroxydocosahexaenoic acid (4-HDHA), whereas PA-ED did not. In vitro experiments demonstrated significantly improved differentiation in RvD4- and 4-HDHA-treated primary osteoblast cultures and reduced the expression of osteoclastogenic factors in GF. Further, P. gingivalis infection of OA-ED animals led to a serum composition that suppressed osteoclastic differentiation in vitro.

CONCLUSIONS

Our results underline the preventive impact of Mediterranean-style OA-EDs by indicating their pro-resolving nature beyond anti-inflammatory properties.

Leisure-time and occupational physical activity demonstrate divergent associations with periodontitis: A population-based study

AIM

To evaluate the association between leisure-time/occupational physical activity (LTPA/OPA) and periodontitis in a nationally representative sample of the U.S.

POPULATION

MATERIALS AND METHODS

Data from 10,679 adults were retrieved from NHANES 2009-2014 database. Physical activity was assessed through the Global Physical Activity Questionnaire, and accordingly, subjects were classified as performing either high or low LTPA/OPA. Periodontal status was assessed through a full-mouth periodontal examination, and subjects were classified according to the AAP/CDC criteria (no, mild, moderate, or severe periodontitis). Simple and multiple regression analyses were applied to study the association between LTPA/OPA and periodontitis/severe periodontitis.

RESULTS

Multiple regression analyses identified high LTPA as a protective indicator for periodontitis (odds ratio [OR] = 0.81; 95% confidence interval [CI]: 0.72-0.92), while high OPA was found to be a significant risk indicator (OR = 1.16; 95% CI: 1.04-1.30). The combination low LTPA/high OPA showed a cumulative independent association with periodontitis (OR = 1.47; 95% CI: 1.26-1.72). Moreover, both high LTPA (OR = 0.72; 95% CI: 0.58-0.90) and high OPA (OR = 1.29; 95% CI: 1.09-1.53) were significantly associated with stronger estimates of severe periodontitis; the same was observed for the combination of low LTPA/high OPA (OR = 1.66; 95% CI: 1.29-2.15).

CONCLUSIONS

LTPA and OPA showed divergent associations with periodontitis.

The Effect of an Optimized Diet as an Adjunct to Non-Surgical Periodontal Therapy in Subjects with Periodontitis: A Prospective Study

Diet and nutrition are generally categorized as modifiable lifestyle risk factors for the development of periodontal disease because diet may influence a person’s inflammatory status. This study aimed to evaluate the efficacy of the application of a diet plan focused on reducing inflammation and oxidative stress in treating periodontitis. Subjects suffering from periodontitis were divided into two groups. Both groups underwent non-surgical periodontal therapy, and in the optimized diet (OD) group, this treatment was associated with a diet plan. The sample consisted of 60 subjects; 32 (53%) were treated in the non-optimized diet group (ND group) and 28 (47%) in the OD group. In both groups, the periodontal treatment significantly improved the recorded periodontal outcomes between T0 and T1 (FMPS, FMBS, CAL, PPD). Inter-group differences were not statistically significant (p < 0.05). The linear regression models showed that the optimized diet was associated with a higher reduction in PPD and FMBS after the treatment, while patients who had higher LDL levels (over 100 mg/mL) had a less favorable improvement of PPD. The application of an improved diet plan can increase the reduction in PPD and FMBS after non-surgical periodontal therapy when compared with periodontal treatment alone.