Does diabetes increase the risk of periodontitis? A systematic review and meta-regression analysis of longitudinal prospective studies

Oral and systemic health in Singapore: Revisiting the past to define the future

OBJECTIVES

This study aimed to identify studies exploring oral and systemic conditions using Singapore data.

METHODS

Studies were searched using the databases PubMed, Embase and Web of Science, with no publication date or language restrictions. Studies analysing Singaporean data were included in this review.

RESULTS

Six domains were identified: pregnancy and gingivitis; tooth eruption, dental caries and early-life factors; Crohn's disease and oral microbiome; diabetes and periodontal diseases; number of teeth, chewing ability and cognitive status; and oral health and pneumonia. Using data from Singapore, oral-systemic studies have prompted reflections on the aetiopathogenesis of oral disorders, such as common causes connecting oral and systemic chronic conditions. Moreover, it is speculated whether oral conditions could be used as a marker to predict future systemic diseases or whether early-life factors could affect the development of oral and systemic immune responses.

CONCLUSIONS

While Singapore provides opportunities to explore challenges connected to healthy ageing, it also explores health development in many stages of life. Singapore has been prioritizing investigations on a healthier life, and new initiatives are paving the way for oral health research across the lifespan.

Lipotoxicity: The missing link between diabetes and periodontitis?

Lipotoxicity refers to the accumulation of lipids in tissues other than adipose tissue (body fat). It is one of the major pathophysiological mechanisms responsible for the progression of diabetes complications such as non-alcoholic fatty liver disease and diabetic nephropathy. Accumulating evidence indicates that lipotoxicity also contributes significantly to the toxic effects of diabetes on periodontitis. Therefore, we reviewed the current in vivo, in vitro, and clinical evidence of the detrimental effects of lipotoxicity on periodontitis, focusing on its molecular mechanisms, especially oxidative and endoplasmic reticulum stress, inflammation, ceramides, adipokines, and programmed cell death pathways. By elucidating potential therapeutic strategies targeting lipotoxicity and describing their associated mechanisms and clinical outcomes, including metformin, statins, liraglutide, adiponectin, and omega-3 PUFA, this review seeks to provide a more comprehensive and effective treatment framework against diabetes-associated periodontitis. Furthermore, the challenges and future research directions are proposed, aiming to contribute to a more profound understanding of the impact of lipotoxicity on periodontitis.

Relationship Between Diabetes Mellitus and Periodontal/Peri-Implant Disease: A Contemporaneous Review

The prevalence of diabetes mellitus (DM), a major chronic disease and a leading cause of death and disability around the world, is rising. According to the latest data, the global prevalence of DM has increased to 463 million (9.3% of adults) in 2019 and is estimated to reach 700 million by 2045. Periodontal disease, result of periodontium inflammation, is a common, chronic disease and has long been considered one of the complications of DM. Moreover, literature reflects a spectrum of conflicting viewpoints on the effect of diabetic conditions on the implant treatment strategies. The current review aims to update the recent epidemiologic evidence regarding the relationship between DM and periodontal/peri-implant disease, emphasising the effects of glycaemic control on the severity of these diseases and describing the pathobiological mechanisms underlying this association. This review's findings indicate a bidirectional relationship between DM and periodontal/peri-implant disease and that this relationship seems causal, implying that controlling these two diseases might help prevent each other's incidence. Additionally, the severity of periodontal/peri-implant disease is directly related to metabolic control. Although patients with diabetes can obtain implant success similar to those in systemically healthy individuals, an increased risk of peri-implantitis has been reported in DM patients. Therefore, the importance of glycaemic control and maintaining proper oral hygiene cannot be overstated.

Clinical and radiographic periodontal status in hypertensive patients with or without obstructive sleep apnea 10 years after diagnosis and CPAP initiation

OBJECTIVES

Through inflammation and hyposalivation, obstructive sleep apnea (OSA) is suggested to affect periodontal status over time. Our aim was to compare the clinical and radiographic periodontal status of hypertensive patients with or without long-term presence of OSA, treated or untreated with continuous positive airway pressure treatment (CPAP).

MATERIALS AND METHODS

In 2007-2009, a screening for OSA was conducted among 394 hypertensive primary care patients. Polygraphy was used to create three groups: no OSA, non-CPAP, or adherent CPAP based on the apnea hypopnea index (AHI). After 10 years, a cross-sectional sleep and periodontal examination including a clinical and radiographic examination, a questionnaire, and a matrix metalloproteinase-8 (MMP-8) chair-side test was conducted. Based on levels of alveolar bone, bleeding on probing (BoP), and probing pocket depth (PPD), patients were categorized into four periodontal stages: periodontal health/gingivitis and three periodontal disease stages. Periodontal status and periodontal stages were compared between the OSA (n = 49), non-CPAP (n = 38), or adherent CPAP (n = 34) groups.

RESULTS

The 121 patients (53% women) had a median age of 71 years. No differences were seen between the OSA groups regarding median number of teeth (p = .061), teeth/implants, (p = .107), plaque index (p = .245), BoP (p = .848), PPD ≥ 4 mm (p = .561), PPD ≥ 6 mm (p = .630), presence of MMP-8 (p = .693) except for bone loss (p = .011). Among patients with stage periodontal health/gingivitis a significant difference was seen, as 70% of those were categorized as no OSA, 20% as non-CPAP, and 10% as adherent CPAP (p = .029). Differences were not seen in periodontal disease stages.

CONCLUSIONS

Hypertensive patients with obstructive sleep apnea (OSA) did not have an adverse clinical periodontal status compared to patients without OSA. However, when combining radiographic and clinical status into periodontal stages, patients without OSA more frequently exhibited periodontal health or gingivitis compared to patients without OSA, regardless of CPAP treatment.

Observational study of selective screening for prediabetes and diabetes in a real-world setting: an interprofessional collaboration method between public dental services and primary health care in Sweden

OBJECTIVE

Describe a method in a real-world setting to identify persons with undiagnosed prediabetes and type 2 diabetes through an interprofessional collaboration between Public Dental Services and Primary Health Care in Regions Stockholm.

DESIGN

A descriptive observational study.

SETTING

The study was conducted at seven sites in the region of Stockholm, Sweden. Each collaborating site consisted of a primary health clinic and dental clinic.

SUBJECTS

Study participants included adults over 18 years of age who visited the Public Dental Services and did not have a medical history of prediabetes or type 2 diabetes.

MAIN OUTCOME MEASURES

Selective screening is conducted in accordance with a risk assessment protocol at the Public Dental Services. In the investigated method, DentDi (Dental and Diabetes), adults diagnosed with caries and/or periodontitis over a cut-off value are referred to the Primary Health Care clinic for screening of prediabetes and type 2 diabetes.

RESULTS

DentDi, introduced at seven sites, between the years 2017 and 2020, all of which continue to use the method today. A total of 863 participants from the Public Dental Services were referred to the Primary Health Care. Of those 396 accepted the invitation to undergo screening at the primary health care centre. Twenty-four individuals did not meet the inclusion criteria, resulting in a total of 372 persons being included in the study. Among the 372 participants, 27% (101) had elevated glucose levels, of which 12 were diagnosed with type 2 diabetes and 89 with prediabetes according to the study classification.

CONCLUSIONS

DentDi is a feasible method of interprofessional collaboration where each profession contributes with the competence included in everyday clinical practice for early identification of persons with prediabetes and type 2 diabetes with a complete chain of care. The goal is to disseminate this method throughout Stockholm County and even other regions in Sweden.

Efficacy of scaling and root planing with and without adjunct Nd:YAG laser therapy on glucose control and periodontal microecological imbalance in periodontitis patients with type 2 diabetes mellitus: a randomized controlled trial

OBJECTIVE

The study aims to determine the effects of Nd:YAG laser-assisted with subgingival scaling and root planing (SRP) treatment on glucose control and the dynamic changes of subgingival microbiome in periodontitis with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Twenty-two patients were split into Nd:YAG group (n = 11) and SRP group (n = 11). Patients in the Nd:YAG group received SRP and auxiliary Nd:YAG laser treatment; patients in the SRP group received SRP treatment only. Periodontal tissue inflammation and glycemic control were assessed and analyzed during the treatment period and the changes of subgingival microbiome were analyzed by full-length 16S rRNA sequencing.

RESULTS

After 3 months of treatment, PD and CAL values improved significantly in the Nd:YAG group compared to the SRP group. BOP in both groups improved significantly after treatment. FPG levels in the Nd:YAG group were significantly reduced after treatment. Porphyromonas and Porphyromonadaceae were enriched in the Nd:YAG group at baseline, and Fusobacteriota, Fusobacteriia, Fusobacteriales, Leptotrichiaceae, and Leptotrichia were enriched after treatment.

CONCLUSION

Nd:YAG laser-assisted SRP therapy has additional benefits in improving periodontal tissue inflammation and blood glucose control in periodontitis patients with T2DM compared with SRP therapy alone and there was a trend towards a decrease in disease-associated taxa and an increase in health-associated taxa following auxiliary Nd:YAG laser treatment.

CLINICAL RELEVANCE

The effects of Nd:YAG laser-assisted SRP treatment on inflammation, glucose control, and subgingival microbiome in periodontitis patients with T2DM were elucidated, and new ideas for the treatment of T2DM periodontitis were provided.

Effects of mouthwash on periodontal pathogens and glycemic control in patients with type 2 diabetes mellitus

Periodontitis is known to be associated with type 2 diabetes mellitus (T2DM), and gargling with mouthwash is known to reduce the incidence of periodontitis by inhibiting periodontal pathogens. However, the effects of mouthwash on oral and systemic conditions in patients with T2DM remain unknown. In this study, we investigated the effects of gargling with mouthwash on the number of red complex species, including Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia, and HbA1c levels in patients with T2DM. Patients were instructed to gargle with water for 6 months, followed by gargling with mouthwash containing chlorhexidine gluconate for the subsequent 6 months. At each clinic visit, saliva was collected and bacterial DNA was extracted to detect red complex species using the polymerase chain reaction technique. The HbA1c level was determined using a blood sample. The number of red complex species significantly decreased in younger or male patients who gargled with mouthwash. Furthermore, HbA1c levels significantly decreased in younger patients or patients with higher HbA1c levels who gargled with mouthwash. These results suggest that gargling with mouthwash reduces the number of red complex species and improves the hyperglycemic status in patients with T2DM, especially younger patients.

Current scientific evidence for why periodontitis should be included in diabetes management

This Perspective provides a brief summary of the scientific evidence for the two-way links between periodontal diseases and hyperglycemia (diabetes mellitus [DM] and pre-DM). It delivers in a nutshell current scientific evidence for manifestations of hyperglycemia on periodontal health status and effects of periodontal diseases on blood glucose levels and in turn incidence, progression, and complications of diabetes. Of outmost importance is presentation of scientific evidence for the potential of routine periodontal treatment to lower blood glucose levels, providing a novel, economical tool in DM management. Non-surgical periodontal treatment ("deep cleaning") can be provided by dental hygienists or dentists in general dental offices, although severe cases should be referred to specialists. Such therapy can decrease the costs of DM care and other health care costs for people with DM. The great importance of a healthy oral cavity free of infection and subsequent inflammation - especially periodontitis that if untreated will cause loosening and eventually loss of affected teeth - has largely gone unnoticed by the medical community as the health care curricula are largely void of content regarding the bi-directional links between oral health and systemic health, despite elevation of blood glucose levels being an integral part of the general systemic inflammation response. The importance of keeping disease-free, natural teeth for proper biting and chewing, smiling, self-esteem, and pain avoidance cannot be overestimated. Medical and dental professionals are strongly encouraged to collaborate in patient-centered care for their mutual patients with - or at risk for - hyperglycemia.

Adjunctive systemic antibiotic effect on periodontal state, salivary enzyme activity, and glycemia imbalance in type-2 diabetics after non-surgical periodontal management

AIM

The current study aimed at analyzing the effect of non-surgical periodontal treatment accompanied by systemic antibiotics on salivary enzyme activities, periodontal parameters, and glycemic control in type-2 diabetic (T2D) patients with chronic periodontitis.

METHODS

The study included 125 type-2 diabetic patients with chronic periodontitis who had good glycemic control (T2Dc), 125 type-2 diabetics who had bad glycemic control (T2Dpc). The 125 T2Dpc were divided randomly into two groups. The first one enrolled 63 T2Dpc and received a non-surgical periodontal treatment (T2Dpc + NST). The second group enrolled 62 T2Dpc and received the non-surgical treatment accompanied by systemic antibiotics (T2Dpc+NST+A). HbA1c, periodontal indices, and salivary enzyme activities were assessed for all groups. The Glycated hemoglobin (HbA1c) was assessed. The Salivary alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransaminase (ALT), lactate dehydrogenase (LDH), and creatine kinase (CK) activities were measured.

RESULTS

The T2Dpc were characterized by the highest probing depth (PPD) and clinical attachment loss (CAL) periodontal scores, as well as ALP, AST, and ALT enzymatic activities. However, BOP did not differ significantly between T2Dc and T2Dpc. Whereas the rest of clinical parameters PI, GI, and OHI-S did not significantly differ between groups. The Pearson's analysis revealed three correlations between ALP-PPD, ALP-CAL, and ALP-BOP (bleeding on probing) in both T2Dc and T2Dpc (P < 0.05). Interestingly, a significant decrease in periodontal indices, salivary enzyme activities, and HbA1c was recorded in T2Dpc+NST+A group.

CONCLUSION

The increase in ALP, AST, and ALT activities reflects the impact of uncontrolled T2D on periodontal tissue alteration. The ALP activity increase was associated with the severity of periodontal status in diabetic patients. In comparison to non-surgical treatment alone, the adjunct use of systemic antibiotics improves periodontal state, enzyme activity, and glycemic control.

An Update on the Interdisciplinary Dental Care Approach for Geriatric Diabetic Patients

Diabetes mellitus is a prevalent health issue escalating worldwide that gives rise to numerous problems. Periodontal disorders are recognized as the sixth consequence associated with diabetes mellitus. Research shows that dental health affects overall health, and this knowledge is changing the dental field. The correct choice of glucose goal levels and the optimal selection of glucose-lowering medications are determined by a comprehensive geriatric assessment, an estimate of life expectancy, and a rationale for therapy at regular intervals in elderly diabetics. This article provides an overview of the correlation between diabetes and oral health, with a specific emphasis on xerostomia, periodontal disease, and dental caries. Thus, dentists play a significant role within the allied health profession by contributing to the provision of oral care for those diagnosed with diabetes, with a special focus on geriatric patients.

Factors Associated with the Extent of Clinical Attachment Loss in Periodontitis: A Multicenter Cross-Sectional Study

Periodontitis has significant public health implications, affecting individuals' overall health, well-being, and quality of life. This study aimed to assess the risk factors associated with the extent of clinical attachment loss (CAL) in a population diagnosed with periodontitis. Six hundred and sixty-seven patients with different degrees of CAL (mild, n = 223; moderate, n = 256; and advanced, n = 188) were enrolled. Socio-demographics, lifestyle, microbiological profiles, specific immune response, obesity, and single-nucleotide polymorphism of the IL1 gene were determined. Unconditional logistic regression models were conducted to determine the factors associated with the extent of CAL. Aging, smoking, microbial factors, plaque index, and IgG2 antibodies against Aggregatibacter actinomycetemcomitans were associated with advanced CAL. IgG2 antibodies against A. actinomycetemcomitans (OR 1.50; CI 95% 1.23-1.81), plaque accumulation (OR 2.69; CI 95% 2.20-3.29), Porphyromonas gingivalis (OR 1.93; CI 95% 1.35-2.76), Tanerella forsythia (OR 1.88; CI 95%1.30-2.70), and current smoking (OR 1.94; CI 95% 1.31-2.87) were associated with advanced CAL. Gene IL polymorphisms, obesity, and stress were not associated with the extent of CAL. Aging, plaque accumulation, smoking, and having antibodies against A. actinomycetemcomitans were the most critical factors associated with advanced CAL. In contrast, obesity, stress, and gene polymorphisms were not associated with the extent of CAL.

Inequalities in healthcare utilisation among adults with type 2 diabetes

AIMS

To examine inequality in dentist, ophthalmologist, and podiatrist attendance among adults with type 2 diabetes in a country with varying degrees of co-payment.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study with a population of 41,181 people with type 2 diabetes resident in the Central Denmark Region in 2019, identified through Danish registers using a prespecified diabetes algorithm. Descriptive statistics and multiple logistic regression were used to examine the attendance at dentist, ophthalmologist, and podiatrist, controlling for sociodemographic and clinical factors. Attendance at dentist, ophthalmologist, and podiatrist were examined separately.

RESULTS

The majority (59.7 %) had attended the ophthalmologist at least once in the preceding year, whereas 46.5 % and 34.2 % had visited the dentist/dental hygienist and podiatrist, respectively. Disposable household income increased attendance significantly, with a clear gradient in the OR of attending the dentist (p < 0.001), whereas age significantly magnified the OR of podiatrist and ophthalmologist attendance (p < 0.001).

CONCLUSIONS

This study provides circumstantial evidence that co-payment can increase inequality in health care attendance, especially for dental attendance, and it further shows that there is significant sociodemographic inequality in healthcare utilisation among people with type 2 diabetes.

Systemic immune-inflammation index in patients with generalized stage III grade C periodontitis

OBJECTIVES

Systemic immune-inflammation index (SII) is a novel, inflammatory biomarker whose role in predicting several chronic systemic diseases has been recently identified. However, its association with generalized stage III grade C periodontitis in young adults remains unknown.

MATERIAL AND METHODS

The study is a multicentered, double-blind, hospital-based case-control clinical study. Periodontal examination comprised of recording plaque index, sites with bleeding on probing, pocket depth and clinical attachment loss for patients with generalized stage III grade C periodontitis and periodontally healthy group. Complete blood counts were obtained and used for calculating SII, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio. Collected data were then subjected to statistical analyses.

RESULTS

SII was significantly higher in patients with generalized stage III grade C periodontitis compared to periodontally healthy individuals (723.87 vs. 537.74 × 109 /L, p < 0.0001). SII is associated with severe periodontitis in young adults (odds ratio [OR]:11.86, 95% CI 9.61-20.76, p < 0.0001) after adjusting for factors found significant in univariate analysis. Receiver operative curve analysis demonstrated a fair predictive validity of SII in detecting generalized stage III grade C periodontitis in young adults (AUC: 0.766, 95%CI 0.731-0.799, p < 0.0001, sensitivity 81.27%, specificity 76.50% and diagnostic accuracy 78.89%). SII did not exhibit superior predictive validity when compared with NLR in the context of generalized stage III grade C periodontitis (AUC for SII: 0.766, 95%CI 0.731-0.799, AUC for NLR: 0.788, 95% CI 0.754-0.819; p = 0.28).

CONCLUSION

SII is associated with generalized stage III grade C periodontitis in young adults.

Oral health and type 2 diabetes in a socioeconomic perspective

AIMS

This study aimed to examine the association between type 2 diabetes and poor self-rated oral health, and to investigate whether such association is modified by socioeconomic position.

METHODS

We conducted a cross-sectional study, including a population aged 18-75 years with self-reported type 2 diabetes (N = 41,884) and a sex-, age- and municipality-matched reference population from the Health in Central Denmark survey (2020). Multivariable logistic regression was used, and effect modification of indicators of socioeconomic position was examined.

RESULTS

Oral health was rated as poor in 37.0% of the population with type 2 diabetes and in 23.8% of the reference population without diabetes. Individuals with diabetes had higher risk of poor oral health (adjusted odds ratio (OR) 1.46 (95% CI: 1.39; 1.53)) than references. Interaction was seen between type 2 diabetes and highest attained education (p < 0.001). Stratified analyses showed higher risk of poor oral health in people with type 2 diabetes across all educational levels.

CONCLUSIONS

People with type 2 diabetes were more likely to rate their oral health as poor than the reference population. Low education strengthened the association between diabetes and poor oral health.

Periodontitis in individuals with few remaining teeth and a high gingival bleeding index increases the probability of dyslipidemia

BACKGROUND

Dyslipidemia, a silent multifactorial condition, is characterized by changes in blood lipid levels, affecting all socioeconomic strata, increasing the risk for atherosclerotic diseases. This study investigated whether there is an association between dyslipidemia and the combined exposure of periodontitis plus the number of remaining teeth, gingival bleeding, or caries.

METHODS

A two-center cross-sectional study was conducted involving 1270 individuals, with a minimum age of 18 years. Socioeconomic and demographic data, health conditions, lifestyle parameters, and anthropometric, biochemical, and oral clinical examinations were performed. The exposures considered were the presence of periodontitis, dental caries, number of remaining teeth, and gingival bleeding. The outcome was dyslipidemia as defined by the Brazilian Guidelines on Dyslipidemia and Prevention of Atherosclerosis. The combined associations between periodontitis plus other oral health conditions and dyslipidemia were estimated using confounder-adjusted prevalence ratios (PRsingle , PRmultiple , for single and multiple covariable adjustments) with 95% confidence intervals (95% CIs), in a Poisson regression model with robust variance.

RESULTS

The occurrence of dyslipidemia was 70.1% and periodontitis was 84.1%. A positive association between periodontitis and dyslipidemia existed: PRsingle  = 1.13; 95% CI: 1.01-1.26. Combined exposure of periodontitis plus <11 remaining teeth (PRmultiple  = 1.23; 95% CI: 1.05-1.43), as well as combined exposure of periodontitis plus ≥10% gingival bleeding and <11 remaining teeth (PRmultiple  = 1.22; 95% CI: 1.03-1.44), represented greater probabilities of 23% and 22% of individuals having a diagnosis of dyslipidemia.

CONCLUSION

Periodontitis combined with fewer than 11 teeth doubled the likelihood of being diagnosed with dyslipidemia.

Periodontal disease in people with a history of psychosis: Results from the UK biobank population-based study

OBJECTIVES

To test the hypotheses that: (1) Prevalence of periodontal disease would be higher in people with a history of psychosis when compared to the general population and (2) Demographic, life-style related factors and co-morbid medical conditions would predict periodontal disease in people experiencing psychosis.

METHODS

The authors performed cross-sectional analysis of baseline data from the UK Biobank study (2007-2010), identifying cases with psychosis using clinical diagnosis, antipsychotic medication, and self-report. Demographic (age, gender, ethnicity, socioeconomic status), lifestyle-related(BMI, blood pressure, smoking and alcohol intake, physical activity) and physical co-morbidities (cancer, cardiovascular, respiratory, inflammatory disease and metabolic conditions) were included as potential risk factors for periodontal disease among people with a history of psychosis using logistic regression analyses. The analysis sample included 502,505 participants.

RESULTS

Risk of periodontal disease was higher in people with psychosis, regardless of how cases were identified. Patients with a clinical diagnosis had the highest proportion of periodontal disease compared to the general population (21.3% vs. 14.8%, prevalence ratio 1.40, 95% CI: 1.26-1.56). Older and female cases were more likely to experience periodontal disease. Lifestyle factors (smoking) and comorbidities (cardiovascular, cancer or respiratory disease) were associated with periodontal disease among people with a history of psychosis.

CONCLUSIONS

The findings suggest that periodontal disease is more common in people with a history of psychosis, compared to the general population. Prevention and early diagnosis of periodontal disease should be a priority for oral health promotion programmes, which should also address modifiable risk factors like smoking which also contribute to co-morbid systemic disease.

Diabetes mellitus promotes susceptibility to periodontitis-novel insight into the molecular mechanisms

Diabetes mellitus is a main risk factor for periodontitis, but until now, the underlying molecular mechanisms remain unclear. Diabetes can increase the pathogenicity of the periodontal microbiota and the inflammatory/host immune response of the periodontium. Hyperglycemia induces reactive oxygen species (ROS) production and enhances oxidative stress (OS), exacerbating periodontal tissue destruction. Furthermore, the alveolar bone resorption damage and the epigenetic changes in periodontal tissue induced by diabetes may also contribute to periodontitis. We will review the latest clinical data on the evidence of diabetes promoting the susceptibility of periodontitis from epidemiological, molecular mechanistic, and potential therapeutic targets and discuss the possible molecular mechanistic targets, focusing in particular on novel data on inflammatory/host immune response and OS. Understanding the intertwined pathogenesis of diabetes mellitus and periodontitis can explain the cross-interference between endocrine metabolic and inflammatory diseases better, provide a theoretical basis for new systemic holistic treatment, and promote interprofessional collaboration between endocrine physicians and dentists.

Effect of subgingival periodontal therapy on glycaemic control in type 2 diabetes patients: Meta-analysis and meta-regression of 6-month follow-up randomized clinical trials

BACKGROUND

Periodontitis worsens the hyperglycaemia in patients with type 2 diabetes mellitus (T2DM). Subgingival instrumentation, with or without surgical access, is the gold-standard treatment for periodontitis. The aim was to summarize the evidence on the effect of subgingival instrumentation (with or without open flap) on the reduction of glycosylated haemoglobin (HbA1c).

METHODS

Nine electronic databases were searched up to 15 February 2023. Twelve randomized controlled trials with at least 6 months of follow-up were included. Studies using systemic or local-delivery antimicrobial therapies were excluded. Meta-analyses were performed using the random-effects model. The sources of heterogeneity were assessed by applying linear meta-regression. Risk of bias was assessed by RoB 2, and certainty of evidence by GRADE.

RESULTS

Eleven studies were included in the quantitative analyses (1374 patients). Subgingival instrumentation resulted in 0.29% lower HbA1c (95% confidence interval: 0.10-0.47; p = .03) compared with non-active treatment.

DISCUSSION

None of the 12 studies were assessed as having low risk of bias. The percentage of females and the time of diabetes diagnosis significantly explained the high level of heterogeneity. Subgingival periodontal therapy results in a significant and clinically relevant improvement in glycaemic control over 6 months in patients with T2DM and periodontitis. The grade of evidence was moderate.

Prioritizing population oral health through public policy in Australia: the Victorian experience

Dental caries, a non-communicable disease, is one of the most prevalent diseases globally and share common modifiable risk factors with obesity such as excess sugar intake. However, prioritization by governments to improve population oral health has been limited and is typically excluded from the discourse of public health policy development. Therefore, interventions that target dental caries can have other co-benefits including obesity prevention. In Victoria, Australia, local government authorities have a regulatory requirement to develop their Municipal Health and Wellbeing Plans. The aim of this paper is to identify whether prioritization for oral health by local government authorities in Victoria has changed through the subsequent renewal of the Victorian Public Health and Wellbeing Plans 2011-2015 and 2019-2023. Three desktop audits for all publicly available Municipal Health and Wellbeing Plans by local government authorities in Victoria were conducted between 2014 and 2022. Key terms related to oral health was searched within these policy documents and categorized into six indicators: (i) included oral health as a priority, (ii) linked healthy eating and oral health, (iii) supported the Achievement Program, (iv) included the Smiles 4 Miles program, (v) advocated for fluoridated drinking water, and (vi) included other strategies related to oral health. Overall, there was statistically significant reduction in five of the six indicators, with the exception for prioritization of other strategies related to oral health such as targeting excess sugar intake and smoking. A multi-sectoral approach, that includes oral health would be advantageous to address the growing burden of non-communicable diseases.

Increased risk of periodontitis in patients with rheumatoid arthritis: A nationwide register study in Norway

AIM

To investigate the risk of periodontitis in rheumatoid arthritis (RA) patients in a nationwide register-based study.

MATERIALS AND METHODS

Patients and controls were defined using ICD-10 codes registered in the Norwegian Patient Registry (NPR), from 2011 to 2017. The 324,232 included subjects had at least one registered diagnostic code for RA (33,040 patients) or diagnostic codes for non-osteoporotic fractures or hip or knee replacement due to osteoarthritis (controls). The outcome was periodontitis, defined by codes for periodontal treatment from the Norwegian Control and Payment of Health Reimbursements Database (KUHR). Hazard ratios (HRs) were calculated for periodontitis in RA patients compared to controls. Generalized additive model in Cox regressions was estimated to visualize periodontitis occurrences as a function of number of RA visits.

RESULTS

The risk of periodontitis increased with increasing number of RA visits. RA patients having 10 or more visits during the 7-year period had a 50% increased risk of periodontitis compared to controls (HR = 1.48, 95% confidence interval [CI]: 1.39-1.59); also, in patients with assumed new RA, an even higher risk estimate was seen (HR = 1.82, 95% CI: 1.53-2.17).

CONCLUSIONS

In this register-based study in which periodontal treatment was used as a surrogate marker for periodontitis, we found an increased risk of periodontitis in RA patients, particularly those with active disease and new RA.

Influence of Occlusal Hypofunction on Alveolar Bone Healing in Rats

The aim of this in vivo study was to investigate the effect of occlusal hypofunction on alveolar bone healing in the absence or presence of an enamel matrix derivative (EMD). A standardized fenestration defect over the root of the mandibular first molar in 15 Wistar rats was created. Occlusal hypofunction was induced by extraction of the antagonist. Regenerative therapy was performed by applying EMD to the fenestration defect. The following three groups were established: (a) normal occlusion without EMD treatment, (b) occlusal hypofunction without EMD treatment, and (c) occlusal hypofunction with EMD treatment. After four weeks, all animals were sacrificed, and histological (hematoxylin and eosin, tartrate-resistant acid phosphatase) as well as immunohistochemical analyses (periostin, osteopontin, osteocalcin) were performed. The occlusal hypofunction group showed delayed bone regeneration compared to the group with normal occlusion. The application of EMD could partially, but not completely, compensate for the inhibitory effects of occlusal hypofunction on bone healing, as evidenced by hematoxylin and eosin and immunohistochemistry for the aforementioned molecules. Our results suggest that normal occlusal loading, but not occlusal hypofunction, is beneficial to alveolar bone healing. Adequate occlusal loading appears to be as advantageous for alveolar bone healing as the regenerative potential of EMD.

Association between periodontal disease and microstructural brain alterations in the Hamburg City Health Study

AIM

The aim of the PAROBRAIN study was to examine the association of periodontal health with microstructural white matter integrity and cerebral small vessel disease (CSVD) in the Hamburg City Health Study, a large population-based cohort with dental examination and brain magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Periodontal health was determined by measuring clinical attachment loss (CAL) and plaque index. Additionally, the decayed/missing/filled teeth (DMFT) index was quantified. 3D-FLAIR and 3D-T1-weighted images were used for white matter hyperintensity (WMH) segmentation. Diffusion-weighted MRI was used to quantify peak width of skeletonized mean diffusivity (PSMD).

RESULTS

Data from 2030 participants were included in the analysis. Median age was 65 years, with 43% female participants. After adjusting for age and sex, an increase in WMH load was significantly associated with more CAL, higher plaque index and higher DMFT index. PSMD was significantly associated with the plaque index and DMFT. Additional adjustment for education and cardiovascular risk factors revealed a significant association of PSMD with plaque index (p < .001) and DMFT (p < .01), whereas effects of WMH load were attenuated (p > .05).

CONCLUSIONS

These findings suggest an adverse effect of periodontal health on CSVD and white matter integrity. Further research is necessary to examine whether early treatment of periodontal disease can prevent microstructural brain damage.

Is value-based healthcare a strategy to achieve universal health coverage that includes oral health? An Australian case study

The 2021 Resolution on Oral Health by the 74th World Health Assembly supports an important health policy direction: inclusion of oral health in universal health coverage. Many healthcare systems worldwide have not yet addressed oral diseases effectively. The adoption of value-based healthcare (VBHC) reorients health services towards outcomes. Evidence indicates that VBHC initiatives are improving health outcomes, client experiences of healthcare, and reducing costs to healthcare systems. No comprehensive VBHC approach has been applied to the oral health context. Dental Health Services Victoria (DHSV), an Australian state government entity, commenced a VBHC agenda in 2016 and is continuing its efforts in oral healthcare reform. This paper explores a VBHC case study showing promise for achieving universal health coverage that includes oral health. DHSV applied the VBHC due to its flexibility in scope, consideration of a health workforce with a mix of skills, and alternative funding models other than fee-for-service.

Pilot Study: The Effectiveness of Hyperbaric Oxygen Therapy in the Treatment of Periodontitis in Patients with Type 2 Diabetes

Periodontitis is a chronic inflammatory disease with multifactorial aetiology. The relationship between periodontal disease and systemic diseases such as diabetes, obesity, metabolic syndrome, atherosclerotic, cardiovascular disease, and cognitive disorders has been the subject of many studies. The purpose of this study was to evaluate the effectiveness of hyperbaric oxygen therapy on periodontal health in patients suffering from periodontitis and type 2 diabetes. The study was conducted with 14 patients. A total of 369 periodontal pockets in the study group and 431 in the control group were examined. For further analysis, the pockets were classified as moderately deep (4-5 mm) and deep (≥6 mm). All patients received standard non-surgical treatment: scaling and root planing (SRP). Additionally, a series of 30 hyperbaric chamber sessions was carried out in the study group. The following parameters were compared between groups: PD (probing depth), CAL (clinical attachment level), and BOP (bleeding on probing). The results of the study showed significantly better results in terms of PD reduction and CAL gain in the study group in comparison to the control group. Both groups showed a reduction in BOP (bleeding on probing) after treatment. The use of hyperbaric oxygen therapy seems to have considerable benefits in patients with type 2 diabetes.

Feasibility of a nursing guide for the oral management of outpatients with diabetes mellitus

Support for nurses is necessary to enable them to practice the oral management of patients with diabetes; however, no support for nurses in this context has been reported. The objective of this study was to verify the feasibility of a nursing guide for the oral management of outpatients with type 2 diabetes, aimed at giving nurses the ability to independently practice oral management for patients with diabetes in an outpatient department. Questionnaires were administered to 25 certified diabetes educator nurses from 54 medical facilities. The evaluation and degree of understanding of the guide were assessed using items in the nursing guide. In addition, opinions and impressions about the guide in the form of free responses were requested. Descriptive statistics were calculated for all measured variables, and data gathered from the free responses were divided into categories based on their similarities and differences. The feasibility of the nursing guide was confirmed, and nurses confidently provided education regarding oral management to patients with diabetes using the guide. These results suggest that a guide may improve nurses' knowledge, skills, and confidence in providing patient education and improve the overall practice of oral management. Further improvements based on the opinions of nurses, such as the expression of terms, implementation of checklists for oral assessment, and identification of devices that can be utilized in a shorter time, are needed to facilitate the implementation of the guide into practice by nurses.

Oral Microbiota in Children and Adolescents with Type 1 Diabetes Mellitus: Novel Insights into the Pathogenesis of Dental and Periodontal Disease

The oral microbiota can be influenced by multiple factors, but only a few studies have focused on the role of glycemic control in determining early alterations of oral microbiota and their association with pathogenesis of both periodontitis and caries. The aim of this study is to evaluate the interplay between bacteria composition, oral hygiene, and glycemic control in a cohort of children with T1D. A total of 89 T1D children were enrolled (62% males, mean age: 12.6 ± 2.2 years). Physical and clinical characteristics, glucometabolic parameters, insulin treatment, and oral hygiene habits data were collected. Microbiological analysis was performed from saliva samples. A high prevalence of cariogenic and periodontopathogens bacteria in our cohort was detected. In particular, in all subjects Actinomyces spp., Aggregatibacter actinomycetemcomitans, Prevotella intermedia, and Lactobacillus spp. were isolated. S. mutans was found in about half of the analyzed sample (49.4%), in particular in patients with imbalance values of glycemic control. Moreover, a higher presence of both S. mutans and Veillonella spp. was detected in subjects with poorer glycemic control, in terms of HbA1c, %TIR and %TAR, even adjusting for age, sex, and hygiene habits as covariates. Virtuous oral hygiene habits, such as frequency of toothbrush changes and professional oral hygiene, negatively correlated with the simultaneous presence of Tannerella forsythia, Treponema denticola, and Porphyromonas gingivalis, red complex bacteria. Our study shows it is crucial to pay attention to glycemic control and regular oral hygiene to prevent the establishment of an oral microbiota predisposing to dental and periodontal pathology in subjects with T1D since childhood.

The impact of gingivitis reduction on lung function: a randomized trial under intensified oral hygiene

BACKGROUND

Periodontal disease and lung function impairment were found to be associated with low-grade systemic or local inflammation, and it might be that gingival/periodontal inflammation triggers lung function due to systemic inflammation or the transfer of oral bacteria or its components to the lung. A recent observational study in non-smoking subjects showed that lung volumes and flow rates were significantly reduced by 71-185 ml for severe gingivitis regardless of the adjustment for potential confounders. The result did not show any confounding by smoking, and the association between gingivitis and lower lung function was not modified by systemic inflammation. The designed interventional trial primarily aims to test the hypothesis that gingivitis reduction by optimized daily oral hygiene, professional tooth cleaning and antibacterial chlorhexidine (CHX)-containing mouth rinse improves lung function in terms of forced vital capacity (FVC) by at least 2%. The secondary objective will test the hypothesis that gingivitis reduction improves forced expiratory volume in 1 s (FEV1) and forced expiratory flow at 25-75% of the pulmonary volume (FEF25-75) by at least 2%. Furthermore, the influence of the oral microbiome will be taken into account.

METHODS

The study has to include 120 non-smoking subjects aged between 18 and 30 years with biofilm-induced gingivitis. The chosen "waiting control group design" will compare the immediate intervention group with the delayed intervention group, which serves as a control group. Dental and gingival status, lung function and oral microbiome will be recorded. The intensified preventive intervention-professional tooth cleaning, one-stage full-mouth disinfection with CHX and safeguarding an optimal daily oral hygiene by each subject-cannot be blinded, but the outcome measurement in terms of lung function tests is blind.

DISCUSSION

This proposed multidisciplinary study has several strengths. Only one previous intervention study with patients with severe periodontitis (mostly smokers) has been performed. It is novel to include non-smoking subjects with mild and potentially reversible oral inflammation. Furthermore, this research is innovative, because it includes evidence-based interventions for gingivitis reduction, standardized measures of the outcome on lung function and oral microbiome and combines expertise from dentistry, lung physiology, oral microbiology and epidemiology/statistical modelling.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00028176. Registered on February 2022.

Advances in the oral microbiota and rapid detection of oral infectious diseases

Several studies have shown that the dysregulation of the oral microbiota plays a crucial role in human health conditions, such as dental caries, periodontal disease, oral cancer, other oral infectious diseases, cardiovascular diseases, diabetes, bacteremia, and low birth weight. The use of traditional detection methods in conjunction with rapidly advancing molecular techniques in the diagnosis of harmful oral microorganisms has expanded our understanding of the diversity, location, and function of the microbiota associated with health and disease. This review aimed to highlight the latest knowledge in this field, including microbial colonization; the most modern detection methods; and interactions in disease progression. The next decade may achieve the rapid diagnosis and precise treatment of harmful oral microorganisms.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

The effect of diabetes mellitus on oral health-related quality of life: A systematic review and meta-analysis study

Background

Diabetes mellitus is related to variable dental and oral complications like xerostomia and periodontal problems. Therefore, diabetes can affect the oral status and oral health-related quality of life (OHRQoL). A systematic review of evidence can determine the association between diabetes and OHRQoL. so, this study aimed to evaluate the effects of diabetes on OHRQoL.

Methods

After determining the PECO and eligible criteria, a comprehensive search was conducted in PubMed, Scopus, Web of Science, and Embase without any restriction. Further searches were performed in Google Scholar and reference lists of selected articles. Two independent reviewers carried out paper selection, data extraction, and quality assessment. A meta-analysis was conducted using a "random effect model" and the standardized mean difference of OHRQoL with a 95% confidence interval (CI) was reported as estimating pooled effect size.

Results

After screening 237 identified records, three case-control and ten cross-sectional studies met eligibility criteria. Two cross-sectional studies were excluded in the quality assessment phase and the rest of the studies have a low or moderate risk of bias. The pooled standardized mean difference between the case and the control groups was 0.148 (95% CI: -0.045 to 0.340).

Conclusion

Diabetes mellitus has no statistical significant association with OHRQoL. Nevertheless, based on the articles' review, it seems that diabetes can lead to functional limitations, physical pain, and psychological discomfort. Also, complications of diabetes adversely affect wellbeing. Hence dentists can play an essential role in the awareness of persons with diabetes about these problems and improve their OHRQoL.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022303038, identifier CRD42022303038.

Association of Glycated Hemoglobin Level with Self-Reported Chewing Problems in Elderly Community-Dwelling Individuals in Japan

Purpose

Chewing problems are associated with increased mortality, geriatric syndromes and poor activities of daily living. Starting in 2018, in Japan, a self-reported questionnaire investigating chewing status was implemented in the annual health checkup program. Considering the bidirectional association between hyperglycemia and poor oral health, it is hypothesized that people with self-reported chewing problems will have relatively poor glycemic profiles. We investigated the metabolic characteristics of elderly community dwellers with self-reported chewing problems, as well as the association between the problems and HbA1c levels.

Patients and Methods

This was a retrospective, cross-sectional study. We reviewed the data of 1018 adults ≥ 65 years of age who had undergone an annual health checkup at Nihon University Hospital during the period from January 2019 through December 2019. The presence of chewing problems was investigated using a self-reported questionnaire constructed based on guidance provided by the Japanese government.

Results

In the 1018 participants, the overall prevalence of chewing problems was 10.4%. Participants with chewing problems showed significantly higher levels and worse categories of HbA1c than those without such problems (HbA1c < 6.0%, 42.5% vs 54.8%; HbA1c 6.0-6.9%, 41.5% vs 37.0%; HbA1c ≥ 7.0%, 16.0% vs 8.2%, p = 0.008). Participants with HbA1c ≥ 7.0% have a significantly increased risk of chewing problems as compared to those with HbA1c < 6.0% (odds ratio 2.76, p = 0.002), even after adjusting for the effects of age, sex, body mass index, eating behaviors, and history of diabetes mellitus.

Conclusion

HbA1c ≥ 7.0% is associated with self-reported chewing problems in elderly Japanese community-dwellers. We thus recommend a proactive assessment of oral conditions for this population.

Prevalence of Chronic Periodontitis and Chronic Stress in the South Indian Population

Background Chronic stress is commonly thought to have a net negative effect on the efficacy of the immune response, leading to an imbalance between host and parasite and consequently resulting in a periodontal breakdown. Aim To identify the prevalence of chronic periodontitis and chronic stress as well as a comparative evaluation of clinical, demographic, and psychoanalytical parameters among the South Indian population. Materials and methods A total of 500 subjects between the ages of 30 and 60 were chosen from the Trivandrum district, Kerala, using multistage random sampling. Subjects were evaluated based on psychoanalytical parameters as well as periodontal examination. Psychoanalytical parameters were measured by the questionnaire method using the perceived stress scale. Periodontal parameters examined were the probing depth, clinical attachment loss, bleeding on probing, simplified oral hygiene index, and community periodontal index (loss of attachment). Statistical Analysis Categorical and quantitative variables were expressed as frequency (percentage) and mean ± SD respectively. Logistic regression analysis was used to analyze the association between the periodontal variables and psychoanalytical variables. All the statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows (IBM Corp., USA). Results A total of 500 subjects, of whom 308 (61.6%) were female and 192 (38.1%) were male, participated in this study. The overall prevalence of periodontitis among all the subjects was found to be 42.4%, and the proportion of periodontitis among the stressed participants was found to be 46.2%, which is 10% higher compared to the non-stressed (36.1%) participants. Conclusion Our study showed an increased frequency of periodontitis among the stressed subjects as compared to the non-stressed subjects. These findings suggest that there is a positive association between chronic stress and chronic periodontitis, but further prospective studies are required to establish the extent of the effect chronic stress has on chronic periodontitis and vice versa.

Effectiveness of periodontal treatment to improve glycemic control: an umbrella review

AIM

The aim of the present umbrella review was to systematically assess existing evidence on the effect of non-surgical periodontal therapy, both per se' and with adjuvants, on glycemic control in patients with type 2 diabetes and periodontitis and to combine quantitative data with a meta-analysis.

MATERIALS AND METHODS

A detailed study protocol was registered on PROSPERO (CRD42021222279). Four electronic databases (Medline via Pubmed, EMBASE, Cochrane Database of Systematic Reviews and Scielo) were searched independently and in duplicate to identify potentially eligible systematic reviews up to March 2022. Two pre-calibrated independent reviewers performed study selection, data extraction and quality assessment with two checklists (AMSTAR 2 and PRISMA). Moreover, general characteristics of primary studies included in each systematic review were abstracted, and JADAD scale was used to assess the risk of bias for included randomized controlled trials. Data from the individual studies included in each meta-analysis were analyzed, using both fixed and random effect model. The statistical heterogeneity was calculated using the Q test and the I² index. The publication bias was evaluated using a funnel plot and Egger's linear regression method.

RESULTS

Sixteen systematic reviews, published between 2010 and 2021, were included for qualitative synthesis. From these systematic reviews, a total of 27 studies were included in the meta-analysis: all of them were randomized clinical trials, except 1 controlled clinical study. A statistically significant mean difference of - 0.49% and of - 0.38% HbA1c reductions was seen respectively at 3- and 6-month post-treatment, favoring the treatment group (non-surgical periodontal therapy alone) compared to the control group (no treatment). The effect of periodontal treatment with the adjunctive use of antibiotics or laser on the glycemic control was not statistically significant compared to non-surgical periodontal therapy alone.

CONCLUSIONS

The findings of the present study, within its limitations, indicated that non-surgical treatment of periodontitis is an efficacious therapy for improving the glycemic control in type 2 diabetes mellitus patients, both at 3- and 6-month follow-up.

Association between Periodontitis and Diabetes Mellitus in the General Population

Purpose-

This study aimed to examine the association between periodontitis and diabetes mellitus.

Methods

Participants with natural teeth in one jaw from the Third United States National Health and Nutrition Examination Survey (1988-1994) were included in this analysis. Participants with moderate (> 4mm attachment loss in ≥ 2 mesial sites or 5mm pocket depth in ≥ 2 mesial sites) or severe (> 6mm attachment loss in ≥ 2 mesial sites and > 5mm pocket depth in ≥ 1 mesial site) periodontitis were classified as having periodontal disease. The rest of the participants were considered without periodontal disease. Diabetes mellitus was defined as fasting glucose ≥ 126mg/dL, hemoglobin A1c ≥ 6.5% or the use of antihyperglycemic medications. Multivariable logistic regression was used to examine the association between periodontitis and diabetes mellitus in all study population and subgroups stratified by demographics and comorbidities.

Results

This analysis included 13,000 participants [mean age 43.8 ± 19.1 years, 47.5% male, 30% whites]. About 12.7% (n = 1,656) of the study population had periodontitis, and 9.2% (n = 1,200) had diabetes. In a multivariable-adjusted model, presence (vs. absence) of periodontitis was associated with 66% increased odds of diabetes (OR (95% CI):1.66 (1.43-1.94); p < 0.001). Compared to those without periodontitis, the odds of diabetes among those with severe periodontitis was much higher (OR (95% CI): 2.31(1.72-3.11); p < 0.001) than in those with moderate periodontitis (OR (95% CI): 1.54(1.30-1.82); p < 0.001).

Conclusions

Periodontitis is associated with prevalent diabetes in a dose-response fashion, suggesting a bidirectional relationship between those two diseases. Patients with periodontal disease should be counseled regarding their elevated risk of diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01010-6.

Comparison of serum levels of vitamin D in periodontitis patients with and without type 2 diabetes and healthy subjects

OBJECTIVE

The purpose of this study is to find out the levels of serum vitamin D in periodontitis patients with and without type 2 diabetes and to compare them with healthy subjects.

METHODS

In this study, 48 periodontitis patients with type 2 diabetes mellitus (PDM), 53 periodontitis patients (P), and 42 controls who were in the age ranges of 30-50 years and had the entry requirements were selected. Plaque index, calculus index, modified gingival index, pocket depth, clinical attachment loss (CAL), and tooth loss were measured. Serum 25(OH)D level was estimated by electrochemiluminescence immunoassay, and fasting blood sugar and glycosylated hemoglobin were estimated by biochemical colorimetric assays.

RESULTS

The mean serum 25(OH)D level was 17.06 ± 10.73, 15.12 ± 7.74, and 14.17 ± 11.04 ηg/ml for PDM, P, and control groups, respectively, showing no statistical difference. The mean CAL was significantly high in diabetic patients as compared to other groups. Prediabetes prevalence was significantly high in periodontitis patients as compared to controls.

CONCLUSIONS

The prevalence of vitamin D insufficiency was high in the population studied. Serum levels of 25(OH)D showed no significant difference between groups. Periodontitis patients showed an elevated risk for diabetes.

Association between Four Dietary Patterns and the Risk of Periodontal Diseases: A Systematic Review and Meta-Analysis

Background: Several dietary patterns are reported as risk factors for several chronic diseases including oral diseases. However, thus far, there has been no comprehensive quantitative analysis of nutrition and periodontal diseases. Methods: This systematic review was conducted according to the PRISMA guidelines. Cohort, case–control, and cross-sectional studies were eligible for inclusion in this study. The Newcastle–Ottawa scale was used to qualitatively assess the risk of bias in the included studies. The number of samples was used for odds ratio calculation, followed by the unadjusted value and 95% confidence interval. Results: Nine papers were included for the systematic review and meta-analysis. The results of screening for database search records showed that four diet patterns (western diet, dairy product intake, sugar intake, and vitamin C intake) have enough data for meta-analysis. The risk of periodontal disease in the western-diet group and the lowest dairy product intake group was 1.05 (0.51–2.13) and 1.28 (0.89–1.84), respectively. The risk of periodontal disease in the highest sugar intake group and the lowest vitamin C intake group was 1.52 (0.79–2.91) and 1.15 (1.08–1.23), respectively. Conclusions: With aging of the population globally, the prevalence of periodontal disease increases, and the associated cost also increases. Though this study, we found foods related to the risk of periodontal disease, and we are confident that it will contribute to lowering the incidence of the disease.

Domiciliary Management of Periodontal Indexes and Glycosylated Hemoglobin (HbA1c) in Type 1 Diabetic Patients with Paraprobiotic-Based Toothpaste and Mousse: Randomized Clinical Trial

Background: Periodontal disease is a chronic inflammation of periodontal tissues. Several systemic diseases are related to this condition. One of the strongest associations is that of periodontitis and type 2 diabetes mellitus (T2DM). On the contrary, the link with type 1 diabetes mellitus (T1DM) has not been extensively investigated. The objective of the present report is to evaluate and compare the effect of two domiciliary oral hygiene protocols on the periodontal clinical status as well as on the metabolic control in patients affected by T1DM. Methods: Sample size calculation required 20 patients per group, therefore 40 patients were equally and randomly assigned to the following home oral care protocols: a probiotic-based one (trial group) and a natural extracts-based one (control group). At the beginning of the study, after 3 and 6 months, the following periodontal indexes were collected: Probing Pocket Depth (PPD), Plaque Index (PI), Clinical Attachment Level (CAL), Bleeding on Probing (BoP), and Glycosylated Hemoglobin (HbA1c). Data underwent statistical analysis (significance threshold: p < 0.05). Results: In both groups, significant decreases in the periodontal clinical indexes were found at various time frames, whereas the levels of HbA1c significantly decreased only in the control group. Conclusions: Both the domiciliary treatments administered can significantly improve PPD, PI, CAL, and BOP parameters, whereas only the natural extracts-based gel seems to decrease HbA1c levels of T1DM patients.

Correlation of Salivary Occult Blood with the Plasma Concentration of Branched-Chain Amino Acids: A Cross-Sectional Study

Background: Plasma branched-chain amino acids (BCAA) levels are predictors of glycometabolic disorders, leading to diabetes. Microbes, including periodontal pathogens, are thought to be associated with elevated plasma BCAA levels. This study aimed to evaluate the relationship between salivary occult blood (SOB) and plasma BCAA levels in middle-aged Japanese individuals. Methods: Sixty-four Japanese individuals aged ≥ 40 years were recruited for this study, which was conducted in Fukuoka Prefecture, Japan, from August to December 2021. Individuals diagnosed with and/or treated for diabetes were excluded from the study. The body mass index (BMI); plasma concentrations of total, high-density, and low-density lipoprotein cholesterol; triglyceride, glucose, and BCAA; and glycosylated hemoglobin ratio were measured. A basic periodontal examination was performed after the SOB test. Results: The median age of participants (men—20; women—44) was 55 (range, 41–78) years. The plasma BCAA concentration in the SOB-positive group (477 [400–658] μmol/L) was higher than that in the SOB-negative group (432 [307–665] μmol/L). Linear regression analysis revealed that SOB remained independently associated with the plasma BCAA level with statistical significance (β = 0.17, p = 0.02) after adjusting for sex, age, and BMI. Conclusions: SOB was positively correlated with plasma BCAA levels in middle-aged Japanese individuals. Thus, SOB may be a predictor of elevated plasma BCAA levels.

Cannabis use and the risk of periodontitis: A two-sample Mendelian randomization study

AIM

This study aimed to leverage human genetic data to investigate whether cannabis use causally affects periodontitis.

MATERIALS AND METHODS

Data were obtained from summary statistics of genome-wide association studies of lifetime cannabis use (N = 184,765), cannabis use disorder (17,068 cases; 357,219 controls), and periodontitis (17,353 cases; 28,210 controls). We performed two-sample Mendelian randomization (MR) analysis using 6 genetic variants as instrumental variables for lifetime cannabis use and 11 variants as instruments for cannabis use disorder to estimate associations with periodontitis.

RESULTS

There was no evidence for an association between genetic liability for lifetime cannabis use or cannabis use disorder with periodontitis. The estimates from the primary analyses were supported in multivariable MR analysis, which considered potential pleiotropic pathways and in weak instrument analyses.

CONCLUSIONS

This study provides little evidence to support a detrimental effect of genetic liability for cannabis use on periodontal health.

Effects of Artificial Intelligence (AI)-Assisted Dental Monitoring Intervention in Patients with Periodontitis: A Randomized Controlled Trial

AIM

To evaluate the effects of an at-home AI-assisted dental monitoring application on treatment outcomes in patients with periodontitis.

MATERIALS AND METHODS

Participants with periodontitis were recruited and randomly assigned into an AI (AI; n = 16), AI and human counseling (AIHC; n = 17), or control (CG; n = 20) group. All participants received nonsurgical periodontal treatment. We employed an AI-assisted tool called DENTAL MONITORING® (DM) intervention, a new technological AI monitoring product that utilizes smartphone cameras for intraoral scanning and assessment. Patients in the AI and AIHC groups respectively received additional (a) DM or (b) DM with real-person counseling over three months. Periodontal parameters were collected at baseline and follow-ups. A mixed-design model analyzed the follow-up effects over time.

RESULTS

The AI and AIHC groups respectively exhibited greater improvement in probing pocket depth [Mean diff = -0.9±0.4 and -1.4±0.3, effect size (ES) = 0.76 and 1.98], clinical attachment level (Mean diff = -0.8±0.3 and -1.4±0.3, ES = 0.84 and 1.77) and plaque index (Mean diff = -0.5±0.2 and -0.7±0.2, ES = 0.93 and 1.81) at 3-month follow-up than the CG did. The AIHC group had a greater reduction in probing pocket depth (ES = 0.46) and clinical attachment level (ES = 0.64) at the 3-month follow-up compared with the AI group.

CONCLUSION

Using AI monitoring at home had a positive effect on treatment outcomes for patients with periodontitis. Patients with AI-assisted health counseling exhibited better treatment outcomes than did patients who used AI monitoring alone. This article is protected by copyright. All rights reserved.

Expediting dental treatment for patients with diabetes mellitus in a university-based dental clinic

PURPOSE

This pilot project was implemented to minimize barriers in access to care, reduce the risk for oral health and systemic diabetes complications, and optimize the health outcomes for patients with diabetes seeking comprehensive dental treatment.

METHODS

The intervention group included patients with diabetes who participated in hemoglobin A1c (HbA1c) testing during their initial dental screening appointment. The participants whose HbA1c value was ≤ 9.0% were expedited into the scheduling queue for the next comprehensive examination appointment. Health literacy was assessed regarding patients' understanding of the connection between oral health and diabetes.

RESULTS

The mean number of days between screening and treatment plan development was decreased by 38.4%. Of the participants in the intervention group with an HbA1c value ≤ 9.0%, 44% rated their understanding of the connection between diabetes and gum disease as "poor", whereas 86% of the patients who were ineligible due to an HbA1c value ≥ 9.1% rated their understanding as "very good" or "excellent".

CONCLUSIONS

Patients with diabetes will continue to benefit from this quality improvement project to minimize barriers to dental care and improve overall health outcomes as this intervention is adopted as a permanent practice change. The need has been highlighted for comprehensive education in practice settings concerning medical and dental collaboration, and patient awareness of the interrelationship between diabetes mellitus and oral disease. An increase in oral examinations, assessment of routine oral health behaviors, and referral to dental providers from the primary care setting is warranted.

Obesity influences the proteome of periodontal ligament tissues following periodontitis induction in rats

BACKGROUND AND OBJECTIVES

Many studies have been conducted to better understand the molecular mechanism involved with periodontitis progression. There has been growing interest in the potential impact of obesity on periodontitis onset and progression, but the mechanisms involved remain to be elucidated. The present study was designed to determine the impact of obesity on experimentally induced periodontitis in rats and identify novel pathways involved.

METHODS

Sixteen Holtzman rats were distributed into two groups (n = 8): ligature-induced periodontitis (P) and obesity plus ligature-induced periodontitis (OP). Obesity was induced by a high-fat diet for 70 days, whereas periodontitis was induced for 20 days, with a cotton thread placed around the upper first molars bilaterally. Alveolar bone loss was measured by microtomographic analysis and histologically by histometry on the hemimaxillae. The protein composition of the periodontal ligament was evaluated by proteomic analysis.

RESULTS

Data analysis (body weight, adipose tissue weight, and blood test) confirmed obesity induction, whereas bone loss was confirmed by micro-CT and histologic analyses. Proteome analysis from the periodontal ligament tissues (PDL) identified 819 proteins, 53 exclusive to the P group, 28 exclusive to the OP group, and 738 commonly expressed. Validation was performed by immunohistochemistry for selected proteins (spondin1, vinculin, and TRAP).

CONCLUSION

Histologically, it was found that obesity did not significantly affect bone loss resulting from periodontitis. However, the present study's findings indicated that obesity affects the proteome of PDL submitted to experimental periodontitis, allowing for identifying potential targets for personalized approaches.

Edentulism is associated with increased risk of all-cause mortality in adult men

BACKGROUND

Prior reports of positive associations between edentulism and all-cause mortality have been limited by onetime assessments of edentulism and inadequate control of known confounding variables. The authors aimed to assess the association between edentulism and mortality using a longitudinal clinical oral health cohort.

METHODS

The authors used data from the Department of Veterans Affairs Dental Longitudinal Study, an ongoing, closed-panel cohort study from 1968 through 2019 (N = 1,229). Dentition status was evaluated through triennial clinical examinations. Mortality was assessed via the National Death Registry. The authors used Cox regression models to estimate the association between edentulism and all-cause mortality after covariate adjustment. Furthermore, the authors calculated propensity scores and assessed hazard ratios (HRs) in a trimmed, matched, and inverse probability weighted sample.

RESULTS

Participants who were edentulous (N = 112) had 1.24 (95% CI, 1.00 to 1.55) times the hazard of all-cause mortality compared with those who were nonedentulous, after adjustment with time-varying covariates. Use of propensity scores in the model resulted in slightly elevated HRs compared with the standard Cox model, regardless of propensity score method; adjusted HRs were 1.35 (95% CI, 1.01 to 1.80) after matching, 1.26 (95% CI, 1.00 to 1.59) after trimming, and 1.29 (95% CI, 1.18 to 1.42) after inverse probability weighting.

CONCLUSIONS

Edentulism was associated with an increased risk of all-cause mortality in a cohort that captured incident edentulism. This association was consistent after multiple methods to account for confounding.

PRACTICAL IMPLICATIONS

The findings of this study suggest that edentulism is associated with an increase in risk of mortality, after accounting for salient confounding variables using multiple approaches. Efforts to improve equitable access to tooth-preserving treatments are critical.

High glucose inhibits the osteogenic differentiation of periodontal ligament stem cells in periodontitis by activating endoplasmic reticulum stress

Background

Periodontitis is a highly prevalent dental disease which is associated with diabetes and is challenging to cure in diabetic patients. However, the mechanism of comorbid diabetes and periodontitis is still unclear. This study aimed to uncover the role of endoplasmic reticulum (ER) stress in high glucose-associated periodontitis.

Methods

Periodontal tissues were obtained from diabetic patients with periodontitis, periodontitis patients without systemic disease, and healthy teeth. The expressions of ER stress-related factors GRP78, ATF6, PERK and XBP1 were detected by quantitative real-time polymerase chain reaction (qRT-PCR) and immumohistochemical staining. Periodontal ligament stem cells (PDLSCs) from three states of periodontal tissues were isolated and cultured as diabetic PDLSCs (dPDLSCs), inflamed PDLSCs (iPDLSCs) and healthy PDLSCs (hPDLSCs), and the cell stemness was assayed. Different concentrations (8, 11, and 25 mmol/L) of D-glucose were used on hPDLSCs to simulate high glucose microenvironment. The changes of osteogenic ability of PDLSCs were observed, and the expressions of ER stress-related factors in different time point (6, 12, 24, and 72 h) were detected. Finally, GRP78 shRNA lentivirus was used to block ER stress on PDLSCs in the 25 mmol/L D-glucose microenvironment, and the osteogenic ability of PDLSCs was observed.

Results

The results showed that the expressions of GRP78, ATF6, PERK, and XBP1 were highest in the diabetic periodontitis group and lowest in the healthy periodontal tissue group (P<0.05). The clone formation, osteogenic and lipogenic differentiation abilities were lowest in dPDLSCs and highest in hPDLSCs. With the increase of glucose concentration, the osteogensis ability of PDLSCs decreased. After 6 hours of stimulation with D-glucose 25 mmol/L, the ER stress pathways in PDLSCs were effectively activated, and the peak value was reached at 12 hours. The decrease in the osteogensis ability of PDLSCs in a high glucose microenvironment reversed when ER stress was blocked.

Conclusions

The osteogenic differentiation ability of PDLSCs cells is inhibited in a high glucose microenvironment, and this effect is realized by ER stress activation. Blocking ER stress can partially restore the reduced osteogenic ability of PDLSCs. These results suggest that high glucose inhibits the osteogenic differentiation ability of PDLSCs by activating ER stress, which ultimately exacerbates periodontitis.

Diabetes Medication Metformin Inhibits Osteoclast Formation and Activity in In Vitro Models for Periodontitis

Diabetes and periodontitis are comorbidities and may share common pathways. Several reports indicate that diabetes medication metformin may be beneficial for the periodontal status of periodontitis patients. Further research using appropriate cell systems of the periodontium, the tissue that surrounds teeth may reveal the possible mechanism. Periodontal ligament fibroblasts anchor teeth in bone and play a role in the onset of both alveolar bone formation and degradation, the latter by inducing osteoclast formation from adherent precursor cells. Therefore, a cell model including this type of cells is ideal to study the influence of metformin on both processes. We hypothesize that metformin will enhance bone formation, as described for osteoblasts, whereas the effects of metformin on osteoclast formation is yet undetermined. Periodontal ligament fibroblasts were cultured in the presence of osteogenic medium and 0.2 or 1 mM metformin. The influence of metformin on osteoclast formation was first studied in PDLF cultures supplemented with peripheral blood leukocytes, containing osteoclast precursors. Finally, the effect of metformin on osteoclast precursors was studied in cultures of CD14⁺ monocytes that were stimulated with M-CSF and receptor activator of Nf-κB ligand (RANKL). No effects of metformin were observed on osteogenesis: not on alkaline phosphatase activity, Alizarin red deposition, nor on the expression of osteogenic markers RUNX-2, Collagen I and Osteonectin. Metformin inhibited osteoclast formation and accordingly downregulated the genes involved in osteoclastogenesis: RANKL, macrophage colony stimulating factor (M-CSF) and osteoclast fusion gene DC-STAMP. Osteoclast formation on both plastic and bone as well as bone resorption was inhibited by metformin in M-CSF and RANKL stimulated monocyte cultures, probably by reduction of RANK expression. The present study unraveling the positive effect of metformin in periodontitis patients at the cellular level, indicates that metformin inhibits osteoclast formation and activity, both when orchestrated by periodontal ligament fibroblasts and in cytokine driven osteoclast formation assays. The results indicate that metformin could have a systemic beneficiary effect on bone by inhibiting osteoclast formation and activity.

Causal Association Between Periodontitis and Type 2 Diabetes: A Bidirectional Two-Sample Mendelian Randomization Analysis

Background: Previous observational studies have reported a bidirectional association between periodontitis and type 2 diabetes, but the causality of these relationships remains unestablished. We clarified the bidirectional causal association through two-sample Mendelian randomization (MR).

Methods: We obtained summary-level data for periodontitis and type 2 diabetes from several published large-scale genome-wide association studies (GWAS) of individuals of European ancestry. For the casual effect of periodontitis on type 2 diabetes, we used five independent single-nucleotide polymorphisms (SNPs) specific to periodontitis from three GWAS. The summary statistics for the associations of exposure-related SNPs with type 2 diabetes were drawn from the GWAS in the Diabetes Genetics Replication and Meta-analysis (DIAGRAM) consortium and the FinnGen consortium R5 release, respectively. For the reversed causal inference, 132 and 49 SNPs associated with type 2 diabetes from the DIAGRAM consortium and the FinnGen consortium R5 release were included, and the summary-level statistics were obtained from the Gene-Lifestyle Interactions in Dental Endpoints consortium. Multiple approaches of MR were carried out.

Results: Periodontitis was not causally related with the risk of type 2 diabetes (all p > 0.05). No causal effect of type 2 diabetes on periodontitis was found (all p > 0.05). Estimates were consistent across multiple MR analyses.

Conclusion: This study based on genetic data does not support a bidirectional causal association between periodontitis and type 2 diabetes.

Longitudinal Observation of Outcomes and Patient Access to Integrated Care Following Point-of-Care Glycemic Screening in Community Health Center Dental Safety Net Clinics

Introduction: Rates of diabetes/prediabetes continue to increase, with disparity populations disproportionately affected. Previous field trials promoted point-of-care (POC) glycemic screening in dental settings as an additional primary care setting to identify potentially at-risk individuals requiring integrated care intervention. The present study observed outcomes of POC hemoglobin A1c (HbA1c) screening at community health center (CHC) dental clinics (DC) and compliance with longitudinal integrated care management among at-risk patients attending dental appointments.

Materials and Methods: POC HbA1c screening utilizing Food and Drug Administration (FDA)-approved instrumentation in DC settings and periodontal evaluation of at-risk dental patients with no prior diagnosis of diabetes/prediabetes and no glycemic testing in the preceding 6 months were undertaken. Screening of patients attending dental appointments from October 24, 2017, through September 24, 2018, was implemented at four Wisconsin CHC-DCs serving populations with a high representation of disparity. Subjects meeting at-risk profiles underwent POC HbA1c screening. Individuals with measures in the diabetic/prediabetic ranges were advised to seek further medical evaluation and were re-contacted after 3 months to document compliance. Longitudinal capture of glycemic measures in electronic health records for up to 2 years was undertaken for a subset (n = 44) of subjects with available clinical, medical, and dental data. Longitudinal glycemic status and frequency of medical and dental access for follow-up care were monitored.

Results: Risk assessment identified 224/915 (24.5%) patients who met inclusion criteria following two levels of risk screening, with 127/224 (57%) qualifying for POC HbA1c screening. Among those tested, 62/127 (49%) exhibited hyperglycemic measures: 55 in the prediabetic range and seven in the diabetic range. Moderate-to-severe periodontitis was more prevalent in patients with prediabetes/diabetes than in individuals with measures in the normal range. Participant follow-up compliance at 3 months was 90%. Longitudinal follow-up documented high rates of consistent access (100 and 89%, respectively), to the integrated medical/DC environment over 24 months for individuals with hyperglycemic screening measures.

Conclusion: POC glycemic screening revealed elevated HbA1c measures in nearly half of at-risk CHC-DC patients. Strong compliance with integrated medical/dental management over a 24-month interval was observed, documenting good patient receptivity to POC screening in the dental setting and compliance with integrated care follow-up by at-risk patients.

Difference in oral microbial composition between chronic periodontitis patients with and without diabetic nephropathy

BACKGROUND

To investigate the difference in the structural composition of salivary flora between chronic periodontitis patients with and without diabetic nephropathy (DN).

METHODS

Thirty salivary samples of 15 chronic periodontitis patients with DN (DN group) and 15 chronic periodontitis patients with diabetes but without DN (DM group) were subjected to pyrosequencing of polymerase chain reaction-amplified 16 s ribosomal RNA genes. After diversity testing, the differential flora were analyzed. The sequencing results were compared with GenBank database to determine the type of differential flora using species composition analysis, hierarchical cluster analysis, principal co-ordinate analysis, and species difference analysis.

RESULTS

There were significant between-group differences with respect to Gemella, Selenomonas spp, Lactobacillales_unclassified, Bacteria-unclassified and Abiotrophia (p < 0.05). Compared with DM group, the relative abundance of Selenomonas spp. in DN group was significantly higher; the area under the receiver operating characteristic curve of Selenomonas spp. was 0.713 (P < 0.05). Multi-level biological identification and feature maps indicated that Selenomonas spp. might be used as a potential biomarker for DN patients. On binary logistic regression analysis, increase of Selenomonas spp. was related with DN.

CONCLUSIONS

We found significant between-group differences in the structural composition of oral flora. The increase in the relative abundance of Selenomonas spp. may be associated with DN in patients with chronic periodontitis.