Changes of adiponectin and inflammatory cytokines after periodontal intervention in type 2 diabetes patients with periodontitis

Improvement of post-periodontitis-therapy inflammatory state in diabetics: a meta-analysis of randomized controlled trials

OBJECTIVES

This systematic review aimed to evaluate the impact of periodontal therapy on systemic biomarkers of inflammation and oxidative stress in patients with type 2 diabetes mellitus (T2DM) and periodontitis.

MATERIALS AND METHODS

An electronic search without restriction on dates or languages was performed in six electronic databases, protocol records and other sources until May 2024. To develop the search strategy, clinical question was formulated using the PICOD method. Eligibility criteria included randomized controlled trials on the effects of periodontitis-therapy on the inflammatory parameters of T2DM patients. Risk of bias and certainty of evidence were assessed by RoB2 and GRADE tools, respectively. The review protocol was registered in PROSPERO platform (CRD42020206295).

RESULTS

Of 1,062 records screened, the authors determined that 14 studies enrolling 1223 participants proved eligible. Moderate-quality evidence suggested a positive effect of periodontitis-therapy on serum levels of c-reactive protein [0.39 (CI95%: 0.27-0.5)], even without the use of antibiotics [0.34 (CI95%: 0.22-0.46)], in T2DM patients. The significant reduction in C-reactive protein (CRP) among smokers in favor of periodontitis-therapy was greatest at six months of follow-up.

CONCLUSIONS

Non-surgical periodontal therapy improved short-term biomarkers of systemic inflammation in T2DM patients, with moderate evidence of improvement in serum levels of high sensitivity-CRP.

CLINICAL RELEVANCE

Systemic inflammation in T2DM patients can be reduced after non-surgical periodontal therapy, which also has the potential to reduce the risk of other important systemic outcomes, such as cardiovascular disease.

Effect of non-surgical periodontal therapy on risk markers of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in the world. Patients with periodontitis have a higher risk of CVD, although a causal relationship between these conditions remains unclear. Non-surgical periodontal therapy (NSPT) is able to control inflammation at local and systemic levels. This study aimed to analyze the effect of NSPT on CVD risk markers.

METHODS

Four electronic databases were searched from their inception to April 1, 2023, to identify and select articles without any language restrictions. Eleven CVD-related markers (e.g., C-reactive protein [CRP], Interleukin-6 [IL-6]) were selected. Meta-analyses were performed using random and fixed effect models. The differences were expressed as weighted mean differences (WMD) and 95% confidence interval (95% CI).

RESULTS

From 1353 studies, twenty-one randomized controlled clinical trials were included in the meta-analysis. Results showed a significant decrease in CRP, IL-6, and systolic blood pressure (SBP) after NSPT.

CONCLUSION

Moderate certainty evidence shows that NSPT has a positive effect on the reduction of IL-6 and SBP in patients with periodontitis, while low certainty evidence shows that NSPT is effective for reduction of CRP. Moderate certainty evidence showed that NSPT did not show a positive effect on low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG), and low certainty evidence showed that NSPT did not show a positive effect on Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), diastolic blood pressure (DBP), and flow-mediated dilatation (FMD).

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews), number CRD42022377565.

Insight of the interrelationship and association mechanism between periodontitis and diabetes mellitus

Periodontitis and diabetes mellitus are two prevalent chronic diseases that have been recognized to exhibit a bidirectional relationship. Individuals with diabetes are more susceptible to periodontitis, and conversely, periodontitis can exacerbate glycemic control in diabetic patients. The underlying mechanisms of this interrelationship involve complex pathways, including inflammatory responses, altered immune functions, and microbial dysbiosis. The mechanistic insights into the interrelationship between periodontitis and diabetes mellitus revolve around the role of inflammation as a common link between the two diseases. Inflammatory mediators such as cytokines, chemokines, and prostaglandins play a crucial role in the pathogenesis and progression of the diseases. The dysregulation of the immune response in diabetes can exacerbate the inflammatory response in periodontitis, leading to increased tissue destruction and bone resorption. The chronic inflammation in periodontitis can contribute to insulin resistance and impaired glycemic control in diabetic patients. Future directions in research aim to further elucidate the molecular mechanisms underlying the interrelationship between periodontitis and diabetes mellitus. Modulating the inflammatory response, restoring microbial balance, and improving glycemic control hold promise in managing both conditions simultaneously. Herein, we will provide an overview of the interrelationship of periodontitis and diabetes mellitus, and retrospect the underlying mechanisms, which may inspire investigators with further research directions.

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.

The association between interleukin family and diabetes mellitus and its complications: An overview of systematic reviews and meta-analyses

OBJECTIVE

To evaluate and summarize the association between interleukin (IL) concentrations and diabetes mellitus (DM) and its complications.

METHODS

Meta-analyses and eligible individual studies of observational studies investigating the associations between IL and DM and its complications were included. The random-effects model was used to estimate the summary effect, and the heterogeneity among studies was assessed using the Q-statistic and the I2 metric; The Egger's regression and the χ2 test were used to test for small study effects and excess significance bias.

RESULTS

This overview identified 34 meta-analyses that investigated the association between IL concentrations and DM and its complications. Meta-analyses of prospective studies indicated that elevated circulating IL-6 and IL-1β had predictive value for the incident of type 2 diabetes mellitus (T2DM), type 1 diabetes mellitus (T1DM) as well as gestational diabetes mellitus (GDM), and the overall Hazard Ratio (HR) of T2DM was 1.28 (95 % CI: 1.17, 1.40; P＜0.001) per 1 log pg/ml increment in IL-6 levels, however, there was no correlation between circulating IL-10 levels and DM. Meanwhile, the increased level of IL-6 was significantly associated several diabetic complications (Diabetic kidney disease[DKD], diabetic peripheral neuropathy[DPN], and cognitive impairment[CI]), and for the diabetic retinopathy (DR), the levels of IL-1β, IL-8 and IL-10 in the aqueous humor and vitreous humor, but not the blood were significantly correlated with it.

CONCLUSION

Multiple ILs, such as the IL-6 and IL-1β, are definitively linked to DM and its complications, and they may be new targets for the diagnosis and treatment, but stronger evidence needs to be confirmed by prospective studies with larger sample sizes and longer observation periods.

Endogenous and microbial biomarkers for periodontitis and type 2 diabetes mellitus

It has been well documented that there is a two-way relationship between diabetes mellitus and periodontitis. Diabetes mellitus represents an established risk factor for chronic periodontitis. Conversely, chronic periodontitis adversely modulates serum glucose levels in diabetic patients. Activated immune and inflammatory responses are noted during diabetes and periodontitis, under the modulation of similar biological mediators. These activated responses result in increased activity of certain immune-inflammatory mediators including adipokines and microRNAs in diabetic patients with periodontal disease. Notably, certain microbes in the oral cavity were identified to be involved in the occurrence of diabetes and periodontitis. In other words, these immune-inflammatory mediators and microbes may potentially serve as biomarkers for risk assessment and therapy selection in diabetes and periodontitis. In this review, we briefly provide an updated overview on different potential biomarkers, providing novel diagnostic and therapeutic insights on periodontal complications and diabetes mellitus.

Periodontal disease and risk of atrial fibrillation or atrial flutter: A systematic review and meta-analysis

Background

We conducted a study to evaluate the risk of atrial fibrillation (AF) and atrial flutter (AFL) in periodontal disease (PD) patients.

Methods

Cohort studies that evaluate the risk of AF or AFL in PD patients were included. The risk was expressed in the pooled odd ratio (OR) with 95% confidence interval (CI).

Results

A total of four cohort studies were included. We found that patients with PD have a significantly higher risk of AF/AFL compared to those without PD with the pooled OR of 1.33 (95% CI 1.29-1.38; p = 0.357, I 2 = 3.0%).

Conclusions

PD increases the risk of AF and AFL.

Association of Dental Infections with Intracranial Atherosclerotic Stenosis

INTRODUCTION

Periodontal disease (PD) and dental caries are oral infections leading to tooth loss that are associated with atherosclerosis and cerebrovascular disease. We assessed the hypothesis that PD and caries are associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

Full-mouth clinical periodontal measurements (7 indices) collected at 6 sites per tooth from 6,155 subjects from the Dental Atherosclerosis Risk in Communities Study (DARIC) without prior stroke were used to differentiate seven PD stages (Periodontal Profile Class [PPC]-I to -VII) and dental caries on coronal dental surface (DS) and dental root surface (DRS). A stratified subset underwent 3D time-of-flight MR angiogram and 3D high isotropic-resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. We evaluated the relationship between PD stage and dental caries with asymptomatic ICAS, graded as no ICAS, <50% ICAS, and ≥50% ICAS.

RESULTS

Among dentate subjects who underwent vascular imaging, 801 (70%) had no ICAS, 232 (20%) had <50% ICAS, and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-I), participants with mild-moderate tooth loss (PPC-VI), severe tooth loss (PPC-VII), and severe PD (PPC-IV) had higher odds of having <50% ICAS. Participants with extensive gingivitis (PPC-V) had significantly higher odds of having ≥50% ICAS. This association remained significant after adjusting for confounding variables: age, gender, race, hypertension, diabetes, dyslipidemia, 3-level education, and smoking status. There was no association between dental caries (DS and DRS) and ICAS <50% and ≥50%.

CONCLUSION

We report significant associations between mild-moderate tooth loss, severe tooth loss, and severe PD with <50% ICAS as well as an association between extensive gingivitis and ≥50% ICAS. We did not find an association between dental caries and ICAS.

Effects of Oral Inflammatory Diseases and Oral Hygiene on Atrial Fibrillation: A Systematic Review

Objective. Research evidence suggests a link between periodontitis (PD) and atrial fibrillation, but the nature of this link is unclear. This study aimed to systematically review and evaluate the association between PD, other oral diseases, and atrial fibrillation and the role of oral hygiene in preventing atrial fibrillation. Methods. We searched the Medline, Embase, Cochrane Library, and Web of Science databases for the clinical study of oral health and atrial fibrillation from inception to November 2022. Oral health conditions included PD and other oral inflammatory diseases, regular oral hygiene, and tooth brushing. The primary outcomes were the risk of new-onset atrial fibrillation in patients with oral disease, the effect of regular oral care on preventing atrial fibrillation, the effect of frequent tooth brushing on preventing atrial fibrillation, and the incidence of atrial fibrillation in PD patients. Results. Eight clinical trials with a total of 4,328,355 patients were included. The result of the research showed that PD and other impaired oral health may be associated with new-onset atrial fibrillation, and its severity was dose-responsive to the risk of atrial fibrillation. The incidence of atrial fibrillation in patients with severe PD was about 16.3%. Moreover, PD may increase the risk of long-term arrhythmia in patients with atrial fibrillation. Regular oral care and frequent tooth brushing can reduce the incidence of atrial fibrillation. Conclusion. Regular and moderate oral hygiene, frequent tooth brushing, and prevention of PD and other oral inflammatory diseases could reduce the occurrence of atrial fibrillation. It is recommended to strengthen the popularization of oral health knowledge in the publicity related to atrial fibrillation.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the third update of a review originally published in 2014, and most recently updated in 2019. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

An information specialist searched five bibliographic databases up to 17 November 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There are no new completed RCTs on this topic since we published our last update in 2019. We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Association between oral health and atrial fibrillation: A systematic review

Background and objective

Poor oral health increases systemic inflammation, which has complex pathophysiologic links with atrial fibrillation (AF). The aim of this comprehensive systematic review was to investigate the association between oral health and AF in terms of new-onset AF and AF recurrence.

Methods

After PROSPERO protocol was registered, PubMed, Scopus, and Cochrane Database of Systematic Reviews were standardly searched from database inception to February 2021. The included studies were assessed for quality and risk of bias using the modified Newcastle-Ottawa scale. The indicators of poorer oral health were the presence of periodontitis, lower frequency of dental scaling, lower frequency of toothbrushing, and lower number of missing teeth.

Results

We initially identified 424 studies; however, only 5 studies met the inclusion criteria. The included studies comprised 3 nationwide population-based retrospective cohort studies, 1 large prospective cohort study, and 1 case-control study that reported the association between oral health and AF. These studies demonstrated that poor oral health was associated with new-onset AF, and may promote AF recurrence and progression. Moreover, AF patients with poorer oral health may have a higher risk of arrhythmias and major adverse cardiovascular events during long-term follow-up.

Conclusion

Improved oral health potentially reduces new-onset AF. Periodontitis prevention, regular dental visits for professional dental scaling, and frequent tooth brushing, are oral health care interventions that contribute to AF protection. Therefore, promoting oral health should be integrated as a part of AF primary prevention.

Periodontal Disease, Atrial Fibrillation and Stroke

BACKGROUND

We recently described the association between periodontal disease (PD) and stroke risk.

PURPOSE

The purpose of this study was to test the association between PD, dental care utilization and incident atrial fibrillation (AF), as well as AF as a mediator to PD- stroke association.

METHODS

In dental cohort of the Atherosclerosis Risk in Communities Study (ARIC), participants without prior AF underwent full-mouth periodontal measurements. PD was defined on an ordinal scale as healthy (referent), mild, moderate and severe. In ARIC main cohort, participants were classified as regular or episodic dental care users. These patients were followed for AF, over 17 years. Cox proportional hazards models adjusted for AF risk factors were used to study relationships between PD severity, dental care utilization and AF. Mediation analysis was used to test if AF mediated the PD- stroke association.

RESULTS

In dental ARIC cohort, 5,958 were assessed without prior AF, 754 were found to have AF. Severe PD was associated with AF on both univariable (crude HR, 1.54; 95% CI, 1.26-1.87) and multivariable (adjusted HR, 1.31, 95% CI, 1.06-1.62) analyses. Mediation analysis suggested AF mediates the association between PD and stroke. In the main ARIC cohort, 9,666 participants without prior AF were assessed for dental care use, 1558 were found to have AF. Compared with episodic users, regular users had a lower risk for AF on univariable (crude HR, 0.82, 95% CI, 0.74-0.90) and multivariable (adjusted HR, 0.88, 95% CI, 0.78-0.99) analyses.

CONCLUSIONS

PD is associated with AF. The association may explain the PD-stroke risk. Regular users had a lower risk of incident AF compared with episodic users.

Adiponectin inhibits lipoplysaccharide-induced inflammation and promotes osteogenesis in hPDLCs

Periodontal diseases are infections of the structures that surround and support the teeth; they are characterized by local inflammation and alveolar bone loss. Most treatments focus on only one aspect, inhibiting inflammation, or promoting osteoblasts. We set out to develop a new method that would intervene in the two aspects simultaneously. Adiponectin (APN), secreted by adipocytes, inhibits the inflammatory response and promotes osteogenesis. However, its role in human periodontal ligament cells (hPDLCs) is unclear. Therefore, we aim to investigate whether APN could suppress lipopolysaccharide (LPS)-induced inflammation and promote osteogenesis in hPDLCs. In the present study, we stimulated hPDLCs with LPS in the presence or absence of APN. Real-time PCR and Western blotting results demonstrated that APN partially inhibited the activation of the classical nuclear factor κ-B (NF-κB) pathway. These results were confirmed by a change of expressions of NF-κB downstream inflammatory genes, such as decreased cyclooxygenase (COX)-2 and tumor necrosis factor α (TNF-α), along with increased interleukin (IL)-10. As for the role of APN in osteogenesis, Alizarin Red S staining showed that APN treatment induced more calcium deposition nodules than controls. We also found that APN enhanced the expression of osteoblast-related genes (osteopontin (OPN), collagen 1, osteocalcin, alkaline phosphatase, runt-related transcription factor 2 (RUNX2), and bone morphogenetic protein 2) in hPDLCs via the APPL1 (the adaptor protein containing PH domain, PTB domain, and leucine zipper motif 1)/p38 signal transduction pathway. Therefore, APN inhibits LPS-induced inflammation and promotes osteogenesis in hPDLCs and may have potential therapeutic value in treating periodontitis by inhibiting the inflammatory lesions and contributing to bone tissue regeneration.

A review of T helper 17 cell-related cytokines in serum and saliva in periodontitis

Periodontitis is a chronic inflammatory disease with a complex underlying immunopathology. Cytokines, as molecular mediators of inflammation, play a role in all stages of disease progression. T helper 17 (Th17) cells are thought to play a role in periodontitis. Th17 cell development and maintenance requires a pro-inflammatory cytokine milieu, with many of the cytokines implicated in the pathogenesis of periodontitis. Serum and saliva are easily accessible biofluids which can represent the systemic and local environment to promote the development of Th17 cells. Here we review human clinical studies that investigate IL-1β, IL-4, IL-6, IL-10, IL-17A, IL-17F, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IFN-γ, sCD40L and TNF-α in serum and saliva in periodontitis. We highlight their putative role in the pathogenesis of periodontitis and place them within a wider context of animal and other clinical studies.

Association between periodontitis and glycosylated haemoglobin before diabetes onset: a cross-sectional study

OBJECTIVES

The aim of the present cross-sectional study was to investigate the association between serum glycosylated haemoglobin (HbA1c) levels and periodontal status in patients with periodontitis (CP) and periodontally healthy controls. Furthermore, the objectives were to determine if the periodontitis influenced the serum HbA1c levels.

MATERIALS AND METHODS

A total of 93 patients with CP and 95 periodontally healthy subjects were enrolled in the present study using a cross-sectional design. At baseline, patients were examined and characterized on a regular basis for blood serum parameters and non-fasting blood samples levels. In all patients, a full periodontal examination was performed and clinical attachment loss (CAL) was the primary outcome variable chosen. The spearman correlation, a stepwise multivariable linear regression, and Jonckheere-Terpstra tests were applied in order to assess the relationship between HbA1c levels and periodontitis.

RESULTS

Patients in the CP group presented a significantly higher median serum level of HbA1c [40.9 (31.2; 45.6) mmol/mol)] compared to patients in the healthy control group [35.3 (29.6; 38.6) mmol/mol)] (p < 0.001). HbA1c levels were negatively correlated with the number of teeth and positively correlated with C-reactive protein levels and all periodontal parameters (p < 0.001). Moreover, there was a significant decrease in the number of teeth when HbA1c levels increased (P-trend < 0.001), while there was a significant increase in periodontal parameters (CAL, p = 0.002); PD, p = 0.008; BOP, p < 0.001) when levels of HbA1c increased.

CONCLUSIONS

Patients with CP and undiagnosed diabetes presented significantly higher serum levels of HbA1c compared to periodontally healthy controls. Moreover, the presence of periodontitis was positively correlated with serum HbA1c levels before diabetes onset.

CLINICAL RELEVANCE

HbA1c levels were positively correlated with the severity of periodontitis before diabetes onset.

A randomized controlled trial of the effects of non-surgical periodontal therapy on cardiac function assessed by echocardiography in type 2 diabetic patients

BACKGROUND

Periodontitis significantly increases the risk of diabetic complications. This clinical trial investigated the effects of periodontal therapy on cardiac function in patients with type 2 diabetes mellitus (T2DM) and periodontitis.

MATERIALS AND METHODS

Fifty-eight subjects with T2DM and periodontitis were randomly allocated to Treatment Group (n = 29) receiving non-surgical periodontal therapy, and Control Group (n = 29) having only oral hygiene instructions with delayed periodontal treatment until completion of this 6-month study. The left ventricle (LV) diastolic function was assessed by echocardiography with the tissue Doppler imaging index (E/e' ratio); and LV hypertrophy was evaluated by LV mass index (LVMI). Blood samples were collected for biochemical analysis.

RESULTS

The intention-to-treat analysis showed that periodontal treatment significantly reduced the E/e' ratio by 1.66 (95% CI: -2.64 to -0.68, p < .01), along with marked improvement of periodontal conditions (p < .05). LVMI was not altered at the 6-month follow-up. The serum levels of N-terminal pro-B type natriuretic peptide (NT-proBNP) as a cardiac stress biomarker, C-reactive protein and interleukin-6 decreased numerically without reaching statistical significance.

CONCLUSION

The present study provides the first evidence that non-surgical periodontal therapy may improve cardiac diastolic function in type 2 diabetic patients with periodontitis.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the second update of a review originally published in 2014, and first updated in 2017. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, two trials registries, and the grey literature to September 2019. We placed no restrictions on the language or date of publication. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to August 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Association of adipokines with rheumatic disease activity indexes and periodontal disease in patients with early rheumatoid arthritis and their first-degree relatives

OBJECTIVE

To evaluate the adipokine levels in early rheumatoid arthritis (eRA) and first-degree relatives (FDR) of patients with RA and establish their association with rheumatic disease activity and periodontal variables.

METHOD

A cross-sectional study with eRA patients, FDR and a healthy population. Adipokine levels, clinical, joint radiological indexes and periodontal variables were evaluated. A descriptive, bivariate analysis was performed based on the adipokine levels by χ² , Fisher's test and Mann-Whitney U test. A logistic regression was made for associations.

RESULTS

High leptin levels were associated with the diagnosis of eRA (odds ratio [OR] = 2.79; 95% CI 1.54-5.07). Early rheumatoid arthritis with high adiponectin levels was less likely to have Multidimensional Health Assessment Questionnaire score >3, body mass index (BMI) >25 and Routine Assessment of Patient Index Data 3 score >12 (OR = 0.16; 95% CI 0.03-0.72). Early rheumatoid arthritis was more likely to present high leptin and interleukin (IL)6 levels with low adiponectin simultaneously (OR = 5.03; 95% CI 1.05-24.0). High leptin levels were associated with the FDR adjusted for IgG2 Porphyromonas gingivalis, swollen joints, P gingivalis and low IL6 (OR = 2.57; 95% CI 1.14-5.95).

CONCLUSION

High adipokine levels in eRA may modulate the disease activity. Having more than 1 adipokine at high serum levels is associated with increased disability, disease activity and BMI, indicating that RA is controlled by adiponectin levels in the early stages of the disease. High leptin levels, presence of P gingivalis and swollen joints may be the factors associated with the development of RA in FDR.

Periodontal, metabolic, and cardiovascular disease: Exploring the role of inflammation and mental health

Previous evidence connects periodontal disease, a modifiable condition affecting a majority of Americans, with metabolic and cardiovascular morbidity and mortality. This review focuses on the likely mediation of these associations by immune activation and their potential interactions with mental illness. Future longitudinal, and ideally interventional studies, should focus on reciprocal interactions and cascading effects, as well as points for effective preventative and therapeutic interventions across diagnostic domains to reduce morbidity, mortality and improve quality of life.

Effects of nonsurgical periodontal treatment on glycated haemoglobin on type 2 diabetes patients (PARODIA 1 study): a randomized controlled trial in a sub-Saharan Africa population

BACKGROUND

There is a burglar association between diabetes and periodontitis. Many studies has shown that periodontitis treatment can help improving glycemic control in diabetes patients but little evidence of non-surgical treatment benefit is available in sub Saharan african diabetes patients. We aimed to assess the effects of non-surgical periodontal treatment (NSPT) of chronic periodontitis on glycaemic control in poorly controlled type 2 diabetes patients (T2D) in a sub-Saharan Africa urban setting.

METHODS

A total of 34 poorly controlled T2D patients with chronic periodontitis aged 51.4 ± 8.8 years (mean ± SD), with known duration of diabetes of 55.5 ± 42.6 months, and HbA1c of 9.3 ± 1.3% were randomly assigned to two groups. The treatment group (Group 1, n = 17) received immediate ultrasonic scaling, scaling and root planning along with subgingival 10% povidone iodine irrigation, whereas the control group (Group 2, n = 17) was assigned to receive delayed periodontal treatment 3 months later. Pharmacological treatment was unchanged and all participants received the same standardized education session on diabetes management and dental hygiene. The primary outcome was the 3-month change in HbA1c from baseline. Plaque index (PI), gingival bleeding index (GBI), pocket depth (PD), clinical attachment loss (CAL) were also assessed prior to, at 6 and 12 weeks after enrolment.

RESULTS

Two subjects in each group were excluded from the study. Data were analyzed on thirty patients (15 per group). Non-surgical periodontal treatment with education for better dental hygiene (group 1) significantly improved all periodontal parameters whereas education only (group 2) improved only the plaque index among all periodontal parameters. Immediate non-surgical periodontal treatment induced a reduction of HbA1c levels by 3.0 ± 2.4 points from 9.7 ± 1.6% at baseline to 6.7 ± 2.0% 3 months after NSPT, (p ˂ 0.001) but the change was not significant in group 2, from mean 8.9 ± 0.9% at baseline vs 8.1 ± 2.6% after 3 months (p = 0.24).

CONCLUSION

Non-surgical periodontal treatment markedly improved glycaemic control with an attributable reduction of 2.2 points of HbA1c in poorly controlled T2D patients in a sub Saharan setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02745015 Date of registration: July 17, 2016 'Retrospectively registered'.

Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis

BACKGROUND

There is an association between chronic periodontitis and cardiovascular disease (CVD). However, it is not known whether periodontal therapy could prevent or manage CVD in patients with chronic periodontitis.

OBJECTIVES

The objective of this systematic review was to investigate the effects of periodontal therapy in preventing the occurrence of, and management or recurrence of, CVD in patients with chronic periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 August 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 7), MEDLINE Ovid (1946 to 31 August 2017), Embase Ovid (1980 to 31 August 2017) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL EBSCO) (1937 to 31 August 2017) . The US National Institutes of Health Trials Registry (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform and Open Grey were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.We also searched the Chinese BioMedical Literature Database (1978 to 27 August 2017), the China National Knowledge Infrastructure (1994 to 27 August 2017), the VIP database (1989 to 27 August 2017) and Sciencepaper Online (2003 to 27 August 2017).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs were considered eligible. Studies were selected if they included patients with a diagnosis of chronic periodontitis and previous CVD (secondary prevention studies) or no CVD (primary prevention studies); patients in the intervention group received active periodontal therapy compared to maintenance therapy, no periodontal treatment or another kind of periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction and risk of bias assessment independently and in duplicate. Any discrepancies between the two authors were resolved by discussion or with a third review author. A formal pilot-tested data extraction form was adopted for the data extraction, and the Cochrane tool for risk of bias assessment was used for the critical appraisal of the literature.

MAIN RESULTS

No studies were identified that assessed primary prevention of CVD in people with periodontitis. One study involving 303 participants with ≥ 50% blockage of one coronary artery or a coronary event within three years, but not the three months prior, was included. The study was at high risk of bias due to deviation from the protocol treatment allocation and lack of follow-up data. The trial compared scaling and root planing (SRP) with community care for a follow-up period of six to 25 months. No data on deaths (all-cause or CVD-related) were reported. There was insufficient evidence to determine the effect of SRP and community care in reducing the risk of CVD recurrence in patients with chronic periodontitis (risk ratio (RR) 0.72; 95% confidence interval (CI) 0.23 to 2.22; very low quality evidence). The effects of SRP compared with community care on high-sensitivity C-reactive protein (hs-CRP) (mean difference (MD) 0.62; -1.45 to 2.69), the number of patients with high hs-CRP (RR 0.77; 95% CI 0.32 to 1.85) and adverse events (RR 9.06; 95% CI 0.49 to 166.82) were also not statistically significant. The study did not assess modifiable cardiovascular risk factors, other blood test results, heart function parameters or revascularisation procedures.

AUTHORS' CONCLUSIONS

We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.

Oral health, diabetes, and body weight

OBJECTIVES

The effects of apical periodontitis (AP) and periodontal disease (PD) on organ weights in rats with diabetes mellitus (DM) were evaluated.

DESIGN

Eighty male rats (Rattus norvegicus albinus, Wistar) were divided into eight groups of ten: normoglycemic (N), AP, PD, AP+PD, DM, DM+AP, DM+PD, and DM+AP+PD. DM was induced by streptozotocin; AP, by dental exposure to the oral environment; and PD, by periodontal ligature. Blood glucose concentration was measured at 0, 6, 15, and 35days; body weight, measured daily; and animals were sacrificed after 30days after induction of oral infections. Liver, kidney, pancreas, brain, heart, lungs, and gonads were each weighed. Glycemia, feed intake, organ weight, and body weight were subjected to statistical analyses (p<0.05).

RESULTS

Glycemic levels were higher in all diabetic groups after day 6, but were consistently similar in normoglycemic groups. Blood glucose was higher in DM+PD and DM+AP+PD groups than in the DM group at days 15 and 35. The feed intake was similar among all groups. Brain, heart, and gonad weights were significantly increased in DM+AP+PD. Kidney and lung weights were increased in DM, regardless of the presence of oral infections. Liver weight was reduced in AP and/or PD. Pancreas weight was reduced in DM, independent of AP or PD. Among the normoglycemic groups, there were no significant differences among organ weights.

CONCLUSION

Apical periodontitis and periodontal disease may potentiate the adverse effects of diabetes.

Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta-analysis

CONTEXT

The effect of periodontal therapy on diabetes outcomes has not been established.

OBJECTIVE

This update examines the effect of periodontal treatment on diabetes outcomes.

DATA SOURCES

Literature since October 2009 using MEDLINE.

STUDY ELIGIBILITY CRITERIA

Published RCTs including periodontal therapy for diabetic subjects, a metabolic outcome, an untreated control group, and follow-up of 3 months.

DATA EXTRACTION

Pre-defined data fields, including study quality indicators were used.

DATA SYNTHESIS

A search revealed 56 publications of which 9 met inclusion criteria. Mean change of HbA1c from baseline was compared across treatment groups. Pooled analysis was based on random effects models.

RESULTS

A meta-analysis indicated a mean treatment effect of -0.36% HbA1c (CI -0.54, -0.19) compared to no treatment after periodontal therapy (p < 0.0001). Heterogeneity tests revealed only minimal evidence of publication bias (I(2 ) = 9%).

LIMITATIONS

Small sample size and high risk of bias remain problematic for studies of this type. Periodontal therapy varied considerably.

CONCLUSION

The modest reduction in HbA1c observed as a result of periodontal therapy in subjects with type 2 diabetes is consistent with previous systematic reviews. Despite this finding, there is limited confidence in the conclusion due to a lack of multi-centre trials of sufficient sample size are lacking.

Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta-analysis

CONTEXT

The effect of periodontal therapy on diabetes outcomes has not been established.

OBJECTIVE

This update examines the effect of periodontal treatment on diabetes outcomes.

DATA SOURCES

Literature since October 2009 using MEDLINE.

STUDY ELIGIBILITY CRITERIA

Published RCTs including periodontal therapy for diabetic subjects, a metabolic outcome, an untreated control group, and follow-up of 3 months.

DATA EXTRACTION

Pre-defined data fields, including study quality indicators were used.

DATA SYNTHESIS

A search revealed 56 publications of which 9 met inclusion criteria. Mean change of HbA1c from baseline was compared across treatment groups. Pooled analysis was based on random effects models.

RESULTS

A meta-analysis indicated a mean treatment effect of _0.36% HbA1c (CI _0.54, _0.19) compared to no treatment after periodontal therapy (p < 0.0001). Heterogeneity tests revealed only minimal evidence of publication bias (I2 = 9%).

LIMITATIONS

Small sample size and high risk of bias remain problematic for studies of this type. Periodontal therapy varied considerably.

CONCLUSION

The modest reduction in HbA1c observed as a result of periodontal therapy in subjects with type 2 diabetes is consistent with previous systematic reviews. Despite this finding, there is limited confidence in the conclusion due to a lack of multi-centre trials of sufficient sample size are lacking.

Effect of hyperlipidemia on response to nonsurgical periodontal therapy: Statin users versus nonusers

Objective:

To evaluate the response to nonsurgical periodontal therapy among hyperlipidemic subjects and whether statin use by hyperlipidemic subjects influences the response.

Materials and Methods:

This study was conducted on 107 chronic periodontitis subjects (35 normolipidemic [NL] controls, 36 hyperlipidemics on nonpharmacological therapy and 36 hyperlipidemics on statins). Periodontal (plaque index, gingival index [GI], probing depth [PD], and clinical attachment level [CAL]) and biochemical (plasma triglyceride [TG], total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], and high-DL-C [HDL-C] levels) examination was done at baseline and 3 months after nonsurgical periodontal treatment.

Results:

Both the NL and statin groups exhibited significantly greater improvement in GI as compared to the hyperlipidemic group on nonpharmacological therapy (P = 0.004 and 0.006, respectively). Mean change in PD correlated negatively with baseline TC (r = −0.306) and LDL-C (r = −0.360) while mean change in GI positively correlated with baseline HDL-C (r = 0.219). Regression analyses revealed that mean change in PD was negatively associated with LDL-C (β = −0.358, P < 0.001) while mean change in GI was positively associated with HDL-C (β = 0.219, P = 0.023).

Conclusions:

While higher baseline lipid levels were somewhat detrimental to the resolution of inflammation postperiodontal treatment, the inclusion of statin therapy among hyperlipidemic subjects seemed to improve clinical response as compared to those devoid of the drug. The findings of the study are suggestive of a possible adjunctive role of statins in periodontal treatment that warrants future studies.

Effect of topical application of melatonin on serum levels of C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in patients with type 1 or type 2 diabetes and periodontal disease

Background

The present clinical trial study was designed to assess the effect of topical application of melatonin on serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and C-reactive protein (CRP) in patients with diabetes and periodontal disease in comparison with healthy controls.

Material and Methods

Serum levels of TNF-α and IL-6 were measured by enzyme-linked immunosorbent assay and CRP by nephelometry by using the proper commercial kits in 30 patients with diabetes and periodontal disease, and also in a control group of 30 healthy subjects. Periodontograms were performed using the Florida Probe®. Patients with diabetes were treated with a topical application of melatonin (1% orabase cream formula) once daily for 20 days. Healthy subjects were treated with a placebo orabase cream.

Results

Patients with diabetes and periodontal disease had significantly higher mean levels of serum TNF-α, IL-6 and CRP than healthy subjects (P < 0.001). Following topical melatonin application, there was a statistically significant decrease in the gingival index and pocket depth (P < 0.001) as well as a significant decrease in IL-6 and CRP serum levels (P < 0.001). Local melatonin application in patients with diabetes and periodontal disease resulted in a significant decrease in CRP and IL-6 serum levels as well as an improvement in the gingival index and pocket depth. Patients with periodontal disease had significantly higher serum CRP, IL-6 and TNF-α values by comparison with healthy subjects.

Conclusions

We conclude that melatonin can modulate the inflammatory action of these molecules in periodontal patients.

Key words:Melatonin, periodontal disease, diabetes mellitus, interleukin-6, tumor necrosis factor-alpha, C-reactive protein, inflammatory markers.

Effect of scaling and root planing on serum interleukin-10 levels and glycemic control in chronic periodontitis and type 2 diabetes mellitus

AIM

Chronic periodontal disease (CPD) and type 2 diabetes mellitus (T2DM) share common pathogenic pathways involving the cytokine network resulting in increased susceptibility to both diseases, leading to increased inflammatory destruction, insulin resistance, and poor glycemic control. Periodontal treatment may improve glycemic control. The aim of this study was to evaluate the effect of scaling and root planing (SRP) of T2DM patients with CPD on hyperglycemia and the levels of serum interleukin-10 (IL-10).

MATERIALS AND METHODS

Forty-five subjects were divided into three groups comprising 15 subjects each as Group 1 (healthy controls), Group 2 (CPD patients), and Group 3 (T2DM patients with CPD). Plaque index, gingival index (GI), probing pocket depths (PPD), clinical attachment loss (AL), bleeding on probing (BoP), random blood sugar, glycosylated hemoglobin (HbA1C), and serum IL-10 were measured at baseline; SRP was performed on Groups 2 and 3 and the selected parameters recorded again at 6 months.

RESULTS

Statistically significant (P < 0.05) differences were observed in the variables at baseline and 6 months after SRP between the three groups using one-way ANOVA. The paired samples t-test for PPD and AL in Group 3 was statistically significant. Group 3 revealed positive correlations between PPD and HbA1C, BoP and IL-10, respectively, at 6 months and a predictable association of HbA1C with PPD and GI, and IL-10 levels with BoP, respectively, at 6 months.

CONCLUSION

Scaling and root planing is effective in reducing blood glucose levels in T2DM patient with pocket depths and effective in elevating systemic IL-10 levels in CPD patients and CPD patients with T2DM.

Periodontal therapy and systemic inflammation in type 2 diabetes mellitus: a meta-analysis

AIM

The aim of this systematic review was to assess the effect of periodontal therapy (PT) on serum levels of inflammatory markers in people with type 2 diabetes mellitus (T2DM).

METHODS OF STUDY SELECTION

A literature search was carried out using MEDLINE via Pubmed, EMBASE, LILACS and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Randomized-controlled trials (RCTs) and controlled clinical trials (CCTs) evaluating the effect of PT on systemic inflammatory markers were deemed eligible. Case series (CS), reports and pilot trials were excluded. Study quality was assessed using the Cochrane Collaboration's risk assessment tool. Meta-analysis was carried out using random effect methods.

RESULTS

The search strategy identified 3,164 potential studies of which 61 were assessed for eligibility and 9 (6 RCTs and 3 CCTs) were included in this systematic review. Three RCTs were classified by the authors as being at low risk of bias and three were "unclear" and classified as uncertain risk of bias. All CCTs were considered to be at a high risk of bias. The meta-analysis showed a statistically significant mean difference (MD) for TNF- α (-1.33 pg/ml, 95% CI: -2.10; -0.56, p<0.001) and CRP (-1.28 mg/l, 95% CI: -2.07; - 0.48, p<0.001) favoring periodontal intervention versus control.

CONCLUSION

The results of this meta-analysis support the hypothesis that PT reduces serum levels of TNF- α and CRP in T2DM individuals. The decrease of inflammatory burden has important implications for metabolic control and can, in part, explain the mechanisms linking periodontitis and increased risk for complications in people with T2DM.

Serum γ-glutamyltransferase level is associated with periodontal disease independent of drinking habits in Japanese adults

Background Non-alcoholic fatty liver disease is considered a hepatic manifestation of metabolic syndrome. Periodontal disease is a mild chronic inflammatory disease with systemic effects, and many studies have indicated an association between metabolic syndrome and periodontitis. In the present study, we investigated the relationship between periodontitis and liver biochemical parameters according to alcohol drinking habits through a cross-sectional study based on data from Japanese people in occupational settings. Material and Methods The subjects were 1510 employees (1218 males, 292 females, mean age 50.4 years) who underwent dental and medical checkups in 2012. Associations between the presence of periodontal pockets and serum levels of liver biochemical parameters were assessed. Results Alanine aminotransferase (ALT) and γ-glutamyltransferase (GGT) levels were higher in subjects with than without periodontal pockets. Multiple logistic regression analysis (adjusting for age, gender, cigarette smoking, and alcohol drinking habits, and components of metabolic syndrome) with GGT or ALT as the dependent variable revealed that there was a significant association between periodontal pockets and GGT (odds ratio, OR=1.48), but not ALT. Similar associations were observed when an analysis was performed according to the presence or absence of alcohol drinking habits; the OR was higher in subjects without (OR=1.84) than with drinking habits (OR=1.41). Conclusions The presence of periodontal pockets was associated with serum levels of GGT, a liver biochemical parameter, in Japanese adults with no drinking habit, suggesting that periodontal disease is associated with liver function, independent of alcohol ingestion.

Periodontitis and type II diabetes: a two-way relationship

For many years an association between diabetes and periodontitis has been suspected. In more recent times this relationship has been suggested to be bidirectional with each condition being able to influence the other. In this review the two-way relationship between diabetes and periodontitis is considered. For this narrative review a very broad search strategy of the literature was developed using both EMBASE and MEDLINE (via PubMed) databases. The reference lists from the selected papers were also scanned, and this provided an additional source of papers for inclusion and further assessment. The data available suggest that diabetes is a risk as well as a modifying factor for periodontitis. Individuals with diabetes are more likely to have periodontitis and with increased severity when diabetes is uncontrolled/poorly controlled. Possible mechanisms of how diabetes affects periodontitis include adipokine-mediated inflammation, neutrophil dysfunction, uncoupling of bone and advanced glycation end-products-receptor for advanced glycation end-products interaction. Evidence is accruing to support how periodontitis can affect diabetes and complications associated with diabetes. There is some evidence demonstrating that periodontal therapy can result in a moderate improvement in glycaemic control. Available evidence indicates that diabetes and peridontitis are intricately interrelated and that each condition has the capacity to influence clinical features of each other.

Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis

BACKGROUND

There is an association between chronic periodontitis and cardiovascular disease (CVD). However, it is not known whether periodontal therapy could prevent or manage CVD in patients with chronic periodontitis.

OBJECTIVES

The objective of this systematic review was to investigate the effects of periodontal therapy in preventing the occurrence of, and management or recurrence of, CVD in patients with chronic periodontitis.

SEARCH METHODS

The electronic databases that were searched were the Cochrane Oral Health Group's Trials Register (to 7 April 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 3), MEDLINE via OVID (1946 to 7 April 2014), EMBASE via OVID (1980 to 7 April 2014), CINAHL via EBSCO (1937 to 7 April 2014), OpenGrey (to 7 April 2014), the Chinese BioMedical Literature Database (1978 to April 2014), the China National Knowledge Infrastructure (1994 to April 2014) and the VIP database (1989 to April 2014). We searched the US National Institutes of Health Trials Register, the World Health Organization (WHO) Clinical Trials Registry Platform and Sciencepaper Online for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs were considered eligible. Studies were selected if they included patients with a diagnosis of chronic periodontitis and previous CVD (secondary prevention studies) or no CVD (primary prevention studies); patients in the intervention group received active periodontal therapy compared to maintenance therapy, no periodontal treatment or another kind of periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction and risk of bias assessment independently and in duplicate. Any discrepancies between the two authors were resolved by discussion or with a third review author. A formal pilot-tested data extraction form was adopted for the data extraction, and the Cochrane Collaboration's tool for risk of bias assessment was used for the critical appraisal of the literature.

MAIN RESULTS

No studies were identified that assessed primary prevention of CVD in people with periodontitis. One study involving 303 participants with ≥ 50% blockage of one coronary artery or a coronary event within three years, but not the three months prior, was included. The study was at high risk of bias due to deviation from the protocol treatment allocation and lack of follow-up data. The trial compared scaling and root planing (SRP) with community care for a follow-up period of six to 25 months. No data on deaths (all-cause or CVD-related) were reported. There was insufficient evidence to determine the effect of SRP and community care in reducing the risk of CVD recurrence in patients with chronic periodontitis (risk ratio (RR) 0.72; 95% confidence interval (CI) 0.23 to 2.22; very low quality evidence). The effects of SRP compared with community care on high-sensitivity C-reactive protein (hs-CRP) (mean difference (MD) 0.62; -1.45 to 2.69), the number of patients with high hs-CRP (RR 0.77; 95% CI 0.32 to 1.85) and adverse events (RR 9.06; 95% CI 0.49 to 166.82) were also not statistically significant. The study did not assess modifiable cardiovascular risk factors, other blood test results, heart function parameters or revascularisation procedures.

AUTHORS' CONCLUSIONS

We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.

Risk factors for periodontal disease

Risk factors play an important role in an individual's response to periodontal infection. Identification of these risk factors helps to target patients for prevention and treatment, with modification of risk factors critical to the control of periodontal disease. Shifts in our understanding of periodontal disease prevalence, and advances in scientific methodology and statistical analysis in the last few decades, have allowed identification of several major systemic risk factors for periodontal disease. The first change in our thinking was the understanding that periodontal disease is not universal, but that severe forms are found only in a portion of the adult population who show abnormal susceptibility. Analysis of risk factors and the ability to statistically adjust and stratify populations to eliminate the effects of confounding factors have allowed identification of independent risk factors. These independent but modifiable, risk factors for periodontal disease include lifestyle factors, such as smoking and alcohol consumption. They also include diseases and unhealthy conditions such as diabetes mellitus, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and vitamin D. These risk factors are modifiable and their management is a major component of the contemporary care of many periodontal patients. Genetic factors also play a role in periodontal disease and allow one to target individuals for prevention and early detection. The role of genetic factors in aggressive periodontitis is clear. However, although genetic factors (i.e., specific genes) are strongly suspected to have an association with chronic adult periodontitis, there is as yet no clear evidence for this in the general population. It is important to pursue efforts to identify genetic factors associated with chronic periodontitis because such factors have potential in identifying patients who have a high susceptibility for development of this disease. Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontal disease seen in clinics and dental practices. Hence, risk factor identification and management has become a key component of care for periodontal patients.

Treatment of periodontitis improves the atherosclerotic profile: a systematic review and meta-analysis

AIM

Systematic review and meta-analyses to study the robustness of observations that treatment of periodontitis improves the atherosclerotic profile.

MATERIAL AND METHODS

Literature was searched in Medline-PubMed, Cochrane CENTRAL and EMBASE, based on controlled periodontal intervention trials, including also a non-intervention group. Data were extracted and meta-analyses were performed.

RESULTS

From 3928 screened studies, 25 trials met the eligibility criteria. These trials enrolled 1748 periodontitis patients. Seven trials enrolled periodontitis patients that were otherwise healthy, 18 trials recruited periodontal patients with various co-morbidities, such as CVD or diabetes. None of the trials used hard clinical endpoints of CVD. However, improvement of endothelial function has been consistently reported. Meta-analyses demonstrated significant weighted mean difference (WMD) for hsCRP (-0.50 mg/l, 95% CI:-0.78; -0.22), IL-6 (-0.48 ng/l, 95% CI: -0.90; -0.06), TNF-α (-0.75 pg/ml, 95% CI: -1.34; -0.17), fibrinogen (-0.47 g/l, 95% CI: -0.76; -0.17), total cholesterol (-0.11 mmol/l, 95% CI: -0.21; -0.01) and HDL-C (0.04 mmol/l, 95% CI: 0.03; 0.06) favouring periodontal intervention. Importantly, periodontitis patients with co-morbidity benefitted most from periodontal therapy; significant WMD were observed for levels of hsCRP (-0.71 mg/l, 95% CI: -1.05; -0.36), IL-6 (-0.87 ng/l, 95% CI: -0.97; -0.78), triglycerides (-0.24 mmol/l, 95% CI: -0.26; -0.22), total cholesterol (-0.15 mmol/l, 95% CI: -0.29; -0.01), HDL-C (0.05 mmol/l, 95% CI: 0.03; 0.06) and HbA1c (-0.43%, 95% CI: -0.60; -0.25).

CONCLUSIONS

This systematic review and meta-analyses demonstrate that periodontal treatment improves endothelial function and reduces biomarkers of atherosclerotic disease, especially in those already suffering from CVD and/or diabetes.

The influence of anti-infective periodontal treatment on C-reactive protein: a systematic review and meta-analysis of randomized controlled trials

Background

Periodontal infections are hypothesized to increase the risk of adverse systemic outcomes through inflammatory mechanisms. The magnitude of effect, if any, of anti-infective periodontal treatment on systemic inflammation is unknown, as are the patient populations most likely to benefit. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to test the hypothesis that anti-infective periodontal treatment reduces systemic c-reactive protein (CRP).

Methods and Findings

MEDLINE, EMBASE, CENTRAL and CINAHL databases were searched using sensitivity-enhancing search terms. Eligible RCTs enrolled patients with periodontal infection, compared a clearly defined anti-infective periodontal intervention (experimental group) to an “inactive control” (no periodontal intervention) or to an “active control” (lower treatment intensity than the experimental group). Mean differences in final CRP values at the earliest post-treatment time point (typically 1-3 months) between experimental and control groups were analyzed using random-effects regression. Among 2,753 possible studies 20 were selected, which included 2,561 randomized patients(median=57). Baseline CRP values were >3.0 mg/L in 40% of trials. Among studies with a control group receiving no treatment, the mean difference in CRP final values among experimental treatment vs. control groups was -0.37 mg/L [95%CI=-0.64, -0.11], (P=0.005), favoring experimental treatment. Trials for which the experimental group received antibiotics had stronger effects (P for interaction=0.03) and the mean difference in CRP final values among experimental treatment vs. control was -0.75 mg/L [95%CI=-1.17,-0.33]. No treatment effect was observed among studies using an active treatment comparator. Treatment effects were stronger for studies that included patients with co-morbidities vs. studies that included “systemically healthy” patients, although the interaction was not significant (P=0.48).

Conclusions

Anti-infective periodontal treatment results in short-term modest reductions in systemic CRP.

Diabetes mellitus and periodontal diseases

A bidirectional relationship between diabetes mellitus (DM) and periodontal diseases (PDs) has been established. It is estimated that patients with poorly controlled DM are 3 times more likely to develop chronic PD compared with normoglycemic individuals despite similar composition in subgingival biofilms. Furthermore, these patients present with increased severity and rapid progression of attachment loss around teeth resulting in edentulism. Treatment of PD results in a modest but significant improvement in glycemic control in patients with DM reflected by a 0.4 % reduction in HbA1c-glycated hemoglobin levels. Compelling evidence from in vitro and animal studies supports a plausible biological explanation for the relationship between the 2 conditions centered on systemic low-grade inflammation. However, the limited number of comparable large randomized clinical trials is reflected in the limited specific guidelines offered by the international organizations for DM and PD regarding the management of the 2 diseases in an individual.

Experimental periodontitis induced by Porphyromonas gingivalis does not alter the onset or severity of diabetes in mice

BACKGROUND AND OBJECTIVE

Diabetes mellitus is believed to increase the risk and severity of periodontitis. However, less evidence is available on the converse effects of periodontitis on diabetes. The objective of the study was to investigate to what degree experimental periodontitis induced by Porphyromonas gingivalis might influence the onset and severity of diabetes in different mouse models.

MATERIAL AND METHODS

Twenty-eight male Tallyho/JngJ mice (type 2 diabetes), 20 male streptozotocin-induced diabetes C57BL/6J mice (type 1 diabetes) and 20 male C57BL/6J mice at 4 wks of age were evenly divided into two groups: periodontal infection and sham infection. Periodontitis was induced by Porphyromonas gingivalis W50 (P. gingivalis) oral inoculation before the development of diabetes. Sham-infected mice received vehicle as control. P. gingivalis in the oral cavity were identified by quantitative polymerase chain reaction. Fasting glucose, body weight and food intake levels were monitored and glucose tolerance tests were performed to assess glucose homeostasis for the onset and progression of diabetes. The level of alveolar bone loss and tumor necrosis factor-alpha were determined in week 20 when mice were killed.

RESULTS

Mice in the infection groups developed more alveolar bone loss than those in sham-infection groups (Tallyho p = 0.021; C57-STZ p = 0.014; C57 p = 0.035). Hyperglycemic mice exhibited significantly more bone loss compared to those normal glucose mice (Tallyho vs. C57 p = 0.029; C57-STZ vs. C57 p = 0.024). The level of tumor necrosis factor-alpha was consistent with that of periodontal bone loss and hyperglycemia. There was no significant effect of mouse species on the amount of bone loss at the same level of blood glucose. No statistically significant difference or trend in glucose metabolism was found between the infection and sham-infection group.

CONCLUSION

Diabetes enhanced the risk for periodontal disease induced by P. gingivalis. However, no converse impact was found between this periodontal infection and onset and severity of diabetes in both type 1 and 2 diabetes mice.

Effectiveness of periodontal treatment to improve metabolic control in patients with chronic periodontitis and type 2 diabetes: a meta-analysis of randomized clinical trials

BACKGROUND

It was recently suggested that scaling and root planing (SRP) may help to improve glycemic and metabolic control in patients with chronic periodontitis (CP) and type 2 diabetes mellitus (DM2); however, the effectiveness of SRP in this role remains unclear. This meta-analysis assesses the effectiveness of SRP in improving glycemic and metabolic control in patients with CP and DM2.

METHODS

A literature search of electronic databases was performed for articles published through May 16, 2012, followed by a manual search of several dental journals. A meta-analysis was conducted according to the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Weighted mean differences (MDs) and 95% confidence intervals (CIs) were calculated for glycated hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), total cholesterol (TC), triglycerides (TG), and high- and low-density lipoprotein cholesterol (HDL and LDL, respectively). All outcomes were evaluated as changes from baseline to the end of follow-up. Heterogeneity was assessed with the χ(2)-based Cochran Q test and I(2) statistic. The level of significance was set at P <0.05.

RESULTS

After the study selection process, five randomized clinical trials were included. Results of the meta-analysis indicated that SRP was effective in the reduction of HbA1c (MD = 0.65; 95% CI 0.43 to 0.88; P <0.05) and FPG (MD = 9.04; 95% CI 2.17 to 15.9; P <0.05), but no significant differences were found in the reduction of TC, TG, HDL, or LDL. No evidence of heterogeneity was detected.

CONCLUSION

The meta-analysis results seem to support the effectiveness of SRP in the improvement of glycemic control in patients with CP and DM2; however, future studies are needed to confirm these results.

Periodontal microcirculation in diabetics: an in vivo non-invasive analysis by means of videocapillaroscopy

Background

Diabetes mellitus is today considered a society-wide disease of a chronic/degenerative nature. Among the secondary effects of diabetes, the one that interests the dental surgeon most is diabetic parodontopathy. The aim of this study was to underline and objectify microcirculatory variations at a periodontal mucous level in type 2 diabetics.

Material/Methods

The study enrolled 80 subjects: 40 subjects with a diagnosis of diabetes mellitus type II (18 males and 22 females, between 44 and 85 years of age); and 40 healthy subjects (17 males and 23 females, between 44 and 78 years of age). All the subjects, both diabetic and healthy, were submitted to a videocapillaroscopic examination of the mucosa of the oral cavity.

Results

The measurements concerning the density (expressed in the number of loops/mm²) of the capillary loops presented differences between the healthy subjects and the diabetic subjects. The average periodontal capillary density (DC-P) was clearly superior in diabetic subjects (35.62±10.40 n°loop/mm²) compared to healthy subjects (17.55±3.88 n°loop/mm²). The statistical analysis was performed by means of the Mann Whitney test. The value of P (p=0.000000986), well below the level of significance, demonstrates the high significance of the results obtained.

Conclusions

The increase in capillary density could suggest the presence of active inflammatory phenomena or, more probably, a tendency to a greater susceptibility to inflammatory phenomena. Ultimately, this study shows that there is some peripheral damage to microcirculation at the masticatory mucous level in diabetic subjects and that such alterations can be instrumentally objectified and quantified through the videocapillaroscopic method.

Diabetes mellitus and periodontitis: a tale of two common interrelated diseases

Diabetes mellitus (a group of metabolic disorders characterized by hyperglycemia) and periodontitis (a microbially induced inflammatory disorder that affects the supporting structures of teeth) are both common, chronic conditions. Multiple studies have demonstrated that diabetes mellitus (type 1 and type 2) is an established risk factor for periodontitis. Findings from mechanistic studies indicate that diabetes mellitus leads to a hyperinflammatory response to the periodontal microbiota and also impairs resolution of inflammation and repair, which leads to accelerated periodontal destruction. The cell surface receptor for advanced glycation end products and its ligands are expressed in the periodontium of individuals with diabetes mellitus and seem to mediate these processes. The association between the two diseases is bidirectional, as periodontitis has been reported to adversely affect glycemic control in patients with diabetes mellitus and to contribute to the development of diabetic complications. In addition, meta-analyses conclude that periodontal therapy in individuals with diabetes mellitus can result in a modest improvement of glycemic control. The effect of periodontal infections on diabetes mellitus is potentially explained by the resulting increase in levels of systemic proinflammatory mediators, which exacerbates insulin resistance. As our understanding of the relationship between diabetes mellitus and periodontitis deepens, increased patient awareness of the link between diabetes mellitus and oral health and collaboration among medical and dental professionals for the management of affected individuals become increasingly important.

Inflammatory cytokines, adiponectin, insulin resistance and metabolic control after periodontal intervention in patients with type 2 diabetes and chronic periodontitis

OBJECTIVE

To evaluate the effects of periodontal intervention on inflammatory cytokines, adiponectin, insulin resistance (IR), and metabolic control and to investigate the relationship between type 2 diabetes mellitus (T2DM) and moderately poor glycemic control and chronic periodontitis.

METHODS AND PATIENTS

A total of 190 moderately poorly controlled (HbA1c between 7.5% and 9.5%) T2DM patients with periodontitis were randomly divided into two groups according to whether they underwent periodontal intervention: T2DM-NT and T2DM-T group. The levels of serum adiponectin, C-reactive protein (CRP), tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), lipid profile, glucose, insulin, homeostasis model of assessment-insulin resistance (HOMA-IR) and homeostasis model assessment of β-cell function (HOMA-β) were measured at baseline and after 3 months.

RESULTS

The levels of clinical periodontal variables, the probing depth, attachment loss, bleeding index, and plaque index were improved significantly in T2DM-T group after 3 months compared to T2DM-NT group (all p<0.01). After 3 months, the serum levels of hsCRP, TNF-α, IL-6, fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), fasting insulin (FINS) and HOMA-IR index decreased, and adiponectin was significantly increased in T2DM-T group compared to those in the T2DM-NT group (p<0.05 or p<0.01).

CONCLUSION

Periodontal intervention can improve glycemic control, lipid profile and IR, reduce serum inflammatory cytokine levels and increase serum adiponectin levels in moderately poorly controlled T2DM patients.