Full-mouth disinfection as a therapeutic protocol for type-2 diabetic subjects with chronic periodontitis: twelve-month clinical outcomes: a randomized controlled clinical trial

Efficacy of Adjunctive Local Antimicrobials to Non-Surgical Periodontal Therapy in Pocket Reduction and Glycemic Control of Patients with Type 2 Diabetes: A Network Meta-Analysis

OBJECTIVE

This network meta-analysis [NMA] investigated the efficacy of adjunctive use of subgingivally delivered antimicrobials to non-surgical periodontal therapy [NSPT] in the glycemic control and periodontal pocket depth (PPD) reduction in patients with type 2 diabetes (T2D).

METHODS

Seven databases, grey literature, and registry platforms were searched up to February 2024 to identify randomized clinical trials (RCT) fulfilling the eligibility criteria. The risk of bias was assessed through Cochrane's tool (RoB 2). Two frequentist NMA were performed using a random-effects model to calculate mean differences (MD) as an effect measure and to quantitatively evaluate the glycated hemoglobin (HbA1c) and PPD. The certainty of evidence was assessed through the GRADE approach in a partially contextualized framework for interpreting results. Ten RCTs were included.

RESULTS

In total, 261 patients were treated with eight different local antimicrobials adjuvants to NSPT (azithromycin gel, clarithromycin gel, tetracycline fiber or ointment, chlorhexidine gel, doxycycline nanospheres, minocycline gel, and satranidazole gel), while 249 patients received NSPT alone or associated to placebo. Considering PPD reduction (8 included studies), the best results were found after six months for satranidazole gel (MD -2.64 mm; 95%CI -3.56, -1.72; moderate evidence certainty). For HbA1c control (7 included studies), doxycycline gel (MD - 0.80%; 95%CI -1.70, 0.10), chlorhexidine gel (MD -0.68%; 95%CI -1.34, -0.02), and tetracycline fiber (MD -0.62%; 95%CI -0.85, -0.39) showed promising results after three months (low evidence certainty).

CONCLUSION

The adjunctive use of satranidazole gel probably reduces PPD after a 6-month follow-up, while doxycycline gel, chlorhexidine gel, and tetracycline fiber may decrease HbA1c values in patients with T2D and periodontitis treated with NSPT after a 3-month follow up.

Efficacy of different protocols of non-surgical periodontal therapy in patients with type 2 diabetes: A systematic review and meta-analysis

The aim of the present systematic review of the literature and meta-analysis was to evaluate the efficacy of different protocols of NSPT without any adjunctive therapy in subjects with type 2 diabetes, by considering clinical and patient-centered outcomes. For the purposes of the study randomized controlled clinical trials with more than 3-month follow-up were searched in MEDLINE, EMBASE, and Cochrane Central. Then the articles were screened for inclusion and considered based on the protocols adopted, the outcome measure, follow-up, and the level of glycemic control. A total of 23 articles about 22 studies were included. NSPT was more effective than just oral hygiene measures/no treatment in reducing periodontal probing depth (PPD) and clinical attachment loss (CAL) at 3 months (0.47 mm [0.29-0.65 mm] and 0.50 mm [0.24-0.76 mm], respectively) and 6 months (0.56 mm [0.28-0.84 mm] and 0.45 mm [0.13-0.77 mm], respectively for PPD and CAL) follow-up (very low and low level of evidence). The meta-analysis found no evidence of a difference between full-mouth disinfection versus quadrant protocol clinical outcomes (very low level of evidence). One study found no evidence of a difference in periodontal clinical response between good versus poor glycemic control. Based on the results of the present research NSPT protocols could be considered more efficacious than others in terms of clinical outcomes in subjects with type 2 diabetes. Moreover, NSPT resulted in efficacious improvement of periodontal parameters and HbA1c levels compared to no treatment or oral hygiene instructions alone.

Efficacy of adjunctive local periodontal treatment for type 2 diabetes mellitus patients with periodontitis: A systematic review and network meta-analysis

OBJECTIVES

To investigate the effectiveness of different adjunctive local treatments combined with non-surgical periodontal therapy (NSPT) to reduce pocket depth (PD), gain clinical attachment level (CAL), and/or reduce glycated hemoglobin (HbA1c) in individuals with both type 2 diabetes mellitus (T2DM) and periodontitis in a systematic review and network meta-analysis.

DATA SOURCES

Publications were searched in Cochrane databases, EMBASE, Google Scholar, MEDLINE, PubMed, opengrey.eu, and www.

CLINICALTRIALS

gov up to May 29, 2024 with no language restriction.

STUDY SELECTION

Only randomized controlled trials (RCTs) were included. Network meta-analysis utilized frequentist models.

DATA

The network meta-analysis of 30 RCTs involving 1224 patients revealed that, in short-term (2-3 months) and medium-term (4-6 months), adjunctive local treatment involving statins or metformin significantly outperformed scaling and root planning (SRP) with/without additional interventions such as photodynamic and laser therapies (PDT/LT), phytotherapy, doxycycline, bisphosphonates, antibiotics, antiseptics, or placebo for reducing PD and/or gaining CAL. In the long-term (>6 months), statins yielded the most significant additional PD reduction and CAL gain, followed by antibiotics, compared to SRP with antiseptics or placebo. Only PDT/LT demonstrated significantly greater HbA1c reduction in the short term compared to SRP with/without statins, antiseptics, or placebo.

CONCLUSION

This study moderately supports that adding metformin or statins locally to NSPT may enhance PD reduction and CAL gain compared to SRP with/without placebo.

CLINICAL SIGNIFICANCE

Clinicians are guided to optimize adjunctive therapies, enhancing the health of patients with type 2 diabetes and periodontitis. A strategic approach is proposed to tackle systemic and oral health challenges simultaneously.

Comparative Evaluation of the Effectiveness of Triphala and Chlorhexidine in Full-mouth Disinfection Treatment of Periodontitis in Type 2 Diabetes Patients

AIM

To evaluate and compare the efficacy of triphala and chlorhexidine (CHX) in the treatment of stages II and III periodontitis with one-stage complete mouth disinfection in type 2 diabetes mellitus (DM) patients.

MATERIALS AND METHODS

A total of 24 type 2 diabetic subjects with either stage II or stage III periodontitis were randomly divided into test and control groups with 12 patients in each group. For control group, full-mouth disinfection (FMD) was done using CHX and for test group, FMD was done using triphala. Clinical parameters were evaluated at baseline and at 6 months which comprised of probing pocket depth (PPD), plaque index (PI), clinical attachment level (CAL), papillary bleeding index (PBI). The primary outcomes considered were a reduction in PPD and a gain in CAL. The data were recorded, tabulated, and statistically analyzed.

RESULTS

The PPD reduction for the test group was 3.38 ± 0.75 mm and for the control group was 3.39 ± 0.76 mm. The CAL gain for the test group was 3.39 ± 0.76 mm and for the control group was 3.18 ± 0.74 mm. Although there was a statistically significant PPD reduction, statistically not significant CAL gain was observed.

CONCLUSION

Both the groups with the FMD protocol showed beneficial results in terms of PPD reduction and CAL gain but the test group showed slightly better results.

CLINICAL RELEVANCE

Clinically, there is more PPD reduction and CAL gain from baseline to 6 months in the test group compared to the control group. Clinically, the test group has more favorable results compared to the control group.

Patients with type 2 diabetes and severe periodontitis harbor a less pathogenic subgingival biofilm than normoglycemic individuals with severe periodontitis

BACKGROUND

Whether, and to what extent, diabetes mellitus (DM) can affect the subgingival biofilm composition remains controversial. Thus, the aim of this study was to compare the composition of the subgingival microbiota of non-diabetic and type 2 diabetic patients with periodontitis using 40 "biomarker bacterial species."

METHODS

Biofilm samples of shallow (probing depth [PD] and clinical attachment level [CAL] ≤3 mm without bleeding) and deep sites (PD and CAL ≥5 mm with bleeding) of patients with or without type 2 DM were evaluated for levels/proportions of 40 bacterial species by checkerboard DNA-DNA hybridization.

RESULTS

A total of 828 subgingival biofilm samples from 207 patients with periodontitis (118 normoglycemic and 89 with type 2 DM) were analyzed. The levels of most of the bacterial species evaluated were reduced in the diabetic compared with the normoglycemic group, both in shallow and in deep sites. The shallow and deep sites of patients with type 2 DM presented higher proportions of Actinomyces species, purple and green complexes, and lower proportions of red complex pathogens than those of normoglycemic patients (P < 0.05).

CONCLUSIONS

Patients with type 2 DM have a less dysbiotic subgingival microbial profile than normoglycemic patients, including lower levels/proportions of pathogens and higher levels/proportions of host-compatible species. Thus, type 2 diabetic patients seem to require less remarkable changes in biofilm composition than non-diabetic patients to develop the same pattern of periodontitis.

Adjunctive subgingival application of Chlorhexidine gel in nonsurgical periodontal treatment for chronic periodontitis: a systematic review and meta-analysis

Background

Subgingival applications of chlorhexidine (CHX) gel are commonly used as an adjunct in nonsurgical periodontal treatment (NSPT) for chronic periodontitis (CP). However, there is lack of systematic review and meta-analysis justifying the effects of adjunctive CHX gel on clinical outcomes. The objective of this meta-analysis was to evaluate the efficacy of adjunctive subgingival administration of CHX gel in NSPT compared to NSPT alone for CP.

Methods

An electronic search of four databases and a manual search of four journals were conducted up to August 2019. Only randomized controlled trials reporting on the clinical outcomes of subgingival use of CHX gel adjunct to scaling and root planing (SRP), as compared to SRP alone or with placebo, for at least 3 months were included. Primary outcomes were probing pocket depth (PPD) reduction and clinical attachment level (CAL) gain at 3 and 6 months, when data on at least three studies were obtained.

Results

Seventeen studies were included for qualitative analysis and seven studies for quantitative analysis (four studies for the application of CHX gel adjunct to SRP at selected sites with at least pocket depth ≥ 4 mm and three studies for comparison of full-mouth disinfection (FMD) with subgingival use of CHX gel and full-mouth scaling and root planing (FMSRP). For subgroups, the clinical outcomes between adjunctive use of Xanthan-based CHX gel (XAN-CHX gel) and CHX gel were analyzed. Results indicated a significant improvement of PPD reduction following local adjunctive administration of XAN-CHX gel for SRP at selected sites (MD: 0.15 mm). However, no difference was found in CAL gain. Moreover, no significant difference was observed in PPD and CAL at both 3 and 6 months post-treatment between FMD and FMSRP.

Conclusion

Adjunctive subgingival administration of XAN-CHX gel at individual selected sites in NSPT appears to provide slight benefits in PPD reduction compared to NSPT alone for CP. Due to the lack of high-quality studies, further studies with larger sample sizes and strict standards are needed to confirm the conclusions.

Effect of periodontal treatment in patients with periodontitis and diabetes: systematic review and meta-analysis

OBJECTIVE

The evidence is inconclusive regarding the effect of periodontal treatment on glycemic control and systemic inflammation in patients with type 2 diabetes (T2D) and periodontitis. To evaluate the effect of scaling and root planing (SRP) on the metabolic control and systemic inflammation of patients with type 2 diabetes (T2D).

METHODOLOGY

A literature search was conducted using the MEDLINE database via PubMed and the Cochrane Central Register of Controlled Trials, from their oldest records up to July 2018. Only randomized clinical trials (RCT) were considered eligible for evaluating the effect of periodontal treatment on markers of metabolic control [glycated hemoglobin (HbA1C)] and systemic inflammation [C-reactive protein (CRP)] in patients with T2D. The quality of the studies was evaluated using the Cochrane Collaboration risk assessment tool. Meta-analyses were performed for HbA1c and CRP using random effects models. The size of the overall intervention effect was estimated by calculating the weighted average of the differences in means (DM) between the groups in each study. Heterogeneity was assessed using the Q-statistic method (x2 and I²). The level of significance was established at p<0.05.

RESULTS

Nine RCT were included. SRP was effective in reducing HbA1c [DM=0.56 (0.36-0.75); p<0.01] and CRP [DM=1.89 (1.70-2.08); p<0.01]. No heterogeneity was detected (I2=0%, p>0.05).

CONCLUSIONS

SRP has an impact on metabolic control and reduction of systemic inflammation of patients with T2D.

The effects of non-surgical periodontal therapy on glycemic control in diabetic patients: A randomized controlled trial

AIM

The present study aimed to monitor the clinical outcomes and the metabolic response of periodontal therapy (non-surgical) in patients with periodontitis (chronic) and uncontrolled diabetes (type 2).

METHODS

Eighty-eight subjects with periodontitis (chronic) and uncontrolled diabetes (type 2) were enrolled in this controlled trial and allocated randomly to the test group (44 patients were received immediate periodontal therapy) or the control group (44 patients were received delayed periodontal therapy). The metabolic and clinical evaluations were conducted at baseline and 3 months. This included clinical attachment level, glycated hemoglobin (HbA1c), bleeding on probing, visible plaque, and pocket depth. The periodontal therapy in this study consists of one-stage scaling and root planning, a combination of systemic antibiotics (amoxicillin 500 mg and metronidazole 400 mg), and oral hygiene instructions.

RESULTS

Regarding clinical and metabolic parameters at baseline, no statistically significant differences were displayed between the two groups. However, at 3-month follow-up period the patients within the test group demonstrated significantly better clinical and metabolic outcomes than patients in the control group.

CONCLUSION

The non-surgical periodontal treatment using a combination of metronidazole and amoxicillin significantly improved the metabolic outcome in addition to periodontal health in diabetic subjects with chronic periodontitis.

Effect of non-surgical periodontal therapy on glycemic control of type 2 diabetes mellitus: a systematic review and Bayesian network meta-analysis

Background

Glycemic control is vital in the care of type 2 diabetes mellitus (T2DM) and is significantly associated with the incidence of clinical complications. This Bayesian network analysis was conducted with an aim of evaluating the efficacy of scaling and root planning (SRP) and SRP + adjuvant treatments in improving glycemic control in chronic periodontitis (CP) and T2DM patients, and to guide clinical practice.

Methods

We searched the Pubmed, Embase, Cochrane Library and Web of Science databases up to 4 May 2018 for randomized controlled trials (RCTs). This was at least three months of the duration of study that involved patients with periodontitis and T2DM without other systemic diseases given SRP. Patients in the control group did not receive treatment or SRP combination with adjuvant therapy. Outcomes were given as HbA1c% and levels fasting plasma glucose (FPG). Random-effects meta-analysis and Bayesian network meta-analysis were conducted to pool RCT data. Cochrane’s risk of bias tool was used to assess the risk of bias.

Results

Fourteen RCTs were included. Most were unclear or with high risk of bias. Compared to patients who did not receive treatment, patients who received periodontal treatments showed improved HbA1c% level, including SRP (the mean difference (MD) -0.399 95% CrI 0.088 to 0.79), SRP + antibiotic (MD 0.62, 95% CrI 0.18 to 1.11), SRP + photodynamic therapy (aPDT) + doxycycline (Doxy) (MD 1.082 95% CrI 0.13 to 2.077) and SRP + laser (MD 0.66 95% CrI 0.1037, 1.33). Among the different treatments, SRP + aPDT + Doxy ranked best. Regarding fasting plasma glucose (FPG), SRP did not show advantage over no treatment (MD 4.91 95% CI − 1.95 to 11.78) and SRP with adjuvant treatments were not better than SRP alone (MD -0.28 95% CI -8.66, 8.11).

Conclusion

The results of this meta-analysis seem to support that periodontal treatment with aPDT + Doxy possesses the best efficacy in lowering HbA1c% of non-smoking CP without severe T2DM complications. However, longer-term well-executed, multi-center trails are required to corroborate the results.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0829-y) contains supplementary material, which is available to authorized users.

Effects of a full-mouth disinfection protocol on the treatment of type-2 diabetic and non-diabetic subjects with mild-to-moderate periodontitis: one-year clinical outcomes

OBJECTIVES

This study compared the clinical effects of a full-mouth disinfection (FMD) protocol for the treatment of mild-to-moderate periodontitis in type 2 diabetic and non-diabetic subjects for up to 1 year. Secondary aim was to evaluate the effects of this therapy on the salivary levels of periodontal pathogens between diabetics and non-diabetics.

MATERIAL AND METHODS

Twenty-six type 2 diabetic subjects and 28 non-diabetic subjects with mild-to-moderate periodontitis received full-mouth scaling and root planing within 24 h, application of chlorhexidine digluconate (CHX) gel in pockets and tongue plus CHX rinses for 14 days. Clinical monitoring was performed at baseline, 3, 6, and 12 months post-therapy. Salivary levels of red complex bacterial species were evaluated at baseline, 6, and 12 months post-therapy by qPCR.

RESULTS

Intention-to-treat analyses were performed for seven diabetics and three non-diabetics that did not return for the 12-month evaluation. Most clinical parameters improved significantly at 3, 6, and 12 months post-therapies for both groups (p < 0.05). Overall, there were no significant differences in clinical parameters between groups after therapy (p > 0.05). At 1 year, 39.3% and 50.0% of the non-diabetic and diabetic subjects, respectively, achieved the desired clinical endpoint for treatment (≤ 4 sites with probing depth ≥ 5 mm) (primary outcome variable) (p > 0.05). FMD did not promote changes in the salivary levels of pathogens in either of the groups (p > 0.05). Levels of T. forsythia were lower in diabetic than in non-diabetic subjects at 6 months post-therapy (p < 0.05).

CONCLUSIONS

Type 2 diabetic subjects and systemically healthy subjects with mild-to-moderate periodontitis responded similarly to the proposed FMD protocol for up to 1 year.

CLINICAL RELEVANCE

There is a general thought that diabetics do not answer as well as non-diabetics to periodontal treatments. However, this study showed that diabetics and non-diabetics respond equally to the FMD protocol.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02643771.

Effect of two periodontal treatment modalities in patients with uncontrolled type 2 diabetes mellitus: A randomized clinical trial

AIM

To evaluate the impact of two non-surgical periodontal treatment modalities on metabolic and periodontal clinical parameters in subjects with type 2 diabetes mellitus (T2DM) and poor glycaemic control and chronic periodontitis.

MATERIAL AND METHODS

A randomized controlled clinical trial was conducted. Ninety-three T2DM subjects with glycosylated haemoglobin (HbA1c) > 7% were randomly assigned to one of two groups receiving scaling with root planing in multiple sessions quadrant-by-quadrant (Q by Q) or within 24 hr (one stage). Periodontal parameters, HbA1c, glycaemia blood levels (FPG) and C-reactive protein (CRP) values were assessed at baseline and at 3 and 6 months post-therapy.

RESULTS

At 6 months, HbA1c had decreased by 0.48% in the Q by Q group and by 0.18% in the one-stage group (p = 0.455). After therapy, subjects with an initial HbA1c < 9% showed an increase of 0.31% (p = 0.145), compared with a decrease of 0.88% (p = 0.006) in those with an initial HbA1c ≥ 9%. Periodontal parameters improved significantly (p < 0.0001) post-therapy, with similar results for both treatment modalities.

CONCLUSION

Periodontal therapy had the greatest impact on HbA1c reduction on patients with an HbA1c > 9% regardless of treatment modality. Both modalities resulted in significant improvements in periodontal parameters.

Twenty Years of Full-Mouth Disinfection: The Past, the Present and the Future

Background:

Conventional periodontal treatment, performed quadrant by quadrant in multiple visits, was re-evaluated in the early 1990s when the full-mouth disinfection concept was introduced. Over the years, several modifications to the full-mouth disinfection approach have been suggested.

Objective:

The purpose of this article is to review the evolution of full-mouth disinfection during the past 20 years, to specify its indications and to consider the prospects for this approach.

Materials and Methods:

An electronic and manual search of the literature, ending in December 2016, was performed by two independent researchers. Only pivotal studies and randomized controlled clinical trials published in the English language that evaluated a new approach to full-mouth disinfection were selected.

Results:

According to the studies included in our analysis (21 articles), several modified full-mouth disinfection protocols have been designed including: full-mouth treatment without chlorhexidine, the extension of hygiene methods and an increase in the duration of post-treatment chlorhexidine use, the replacement of chlorhexidine with other antiseptics, supplementation with antibiotics or probiotics, full-mouth antimicrobial photodynamic therapy and one-stage full-mouth disinfection combined with a periodontal dressing.

Conclusion:

Since 1995, several modifications have been suggested to improve the effectiveness of full-mouth disinfection. The majority of the studies demonstrate that the results obtained with full-mouth disinfection and its variants are equivalent to each other and to those obtained with the conventional quadrant method. Currently, the selection of this technique remains empirical and depends on the preferences of the practitioner and the patient. In the future, a patient-centered approach should be the best indication for the use of this technique.

The effects of non-surgical periodontal treatment on glycemic control, oxidative stress balance and quality of life in patients with type 2 diabetes: A randomized clinical trial

Aim

The purpose of this study was to investigate the effects of non-surgical periodontal treatment on hemoglobinA1c (HbA1c) levels, oxidative stress balance and quality of life (QOL) in patients with type 2 diabetes mellitus (T2DM) compared to no periodontal treatment (simple oral hygiene instructions only).

Methods

The design was a 6-month, single-masked, single center, randomized clinical trial. Patients had both T2DM and chronic periodontitis. Forty participants were enrolled between April 2014 and March 2016 at the Nephrology, Diabetology and Endocrinology Department of Okayama University Hospital. The periodontal treatment group (n = 20) received non-surgical periodontal therapy, including scaling and root planing plus oral hygiene instructions, and consecutive supportive periodontal therapy at 3 and 6 months. The control group (n = 17) received only oral hygiene instructions without treatment during the experimental period. The primary study outcome was the change in HbA1c levels from baseline to 3 months. Secondary outcomes included changes in oxidative stress balance (Oxidative-INDEX), the Diabetes Therapy-Related QOL and clinical periodontal parameters from baseline to 3 months and baseline to 6 months.

Results

Changes in HbA1c in the periodontal treatment group were not significantly different with those in the control group at 3 and 6 months. Systemic oxidative stress balance and QOL significantly improved in the periodontal treatment group compared to the control group at 3 months. In the subgroup analysis (moderately poor control of diabetes), the decrease in HbA1c levels in the periodontal treatment group was greater than that in the control group at 3 months but not significant.

Conclusions

In T2DM patients, non-surgical periodontal treatment improved systemic oxidative stress balance and QOL, but did not decrease HbA1c levels at 3 months follow-up.

Trial registration

Current Controlled Trials UMIN-ICDR UMIN 000013278 (Registered April 1, 2014).

Correlation between periodontal disease management and metabolic control of type 2 diabetes mellitus. A systematic literature review

Background

Diabetes and periodontal disease share common features in terms of inflammatory responses. Current scientific evidence suggests that treatment of periodontal disease might contribute to glycemic control. The objective of the study is a review of the last three years.

Material and Methods

A literature search was performed in the MEDLINE (PubMed), Cochrane, and Scopus databases, for articles published between 01-01-2013 and 30-06-2015, applying the key terms “periodontal disease” AND “diabetes mellitus”. The review analyzed clinical trials of humans published in English and Spanish.

Results

Thirteen clinical trials were reviewed, representing a total of 1,912 patients. Three of them had samples of <40 patients, making a total of 108 patients and the remaining ten samples had >40 patients, representing a total of 1,804. Only one article achieved a Jadad score of five. Seven articles (998 patients, 52.3% total), presented a statistically significant decrease in HbA1c (p< 0.05) as a result of periodontal treatment. In the six remaining articles (representing 914 patients, 47.8% of the total), the decrease in HbA1c was not significant. Patient follow-up varied between 3 to 12 months. In three articles, the follow-up was of 3, 4, and 9 months, in two 6 and 12 months.

Conclusions

The majority of clinical trials showed that radicular curettage and smoothing, whether associated with antibiotics or not, can improve periodontal conditions in patients with diabetes mellitus. However, few studies suggest that this periodontal treatment improves metabolic control. However, there is no clear evidence of a relation between periodontal treatment and improved glycemic control in patients with type 2 diabetes mellitus.

Key words:Diabetes, periodontal disease, HbA1c, metabolic control.

Periodontal treatment and glycaemic control in patients with diabetes and periodontitis: an umbrella review

BACKGROUND

Studies suggest that non-surgical periodontal treatment improves glycaemic control in patients with diabetes and periodontitis. The aim of this umbrella review is to summarize the effects of periodontal treatment on glycaemic control in patients with periodontitis and diabetes.

METHODS

A systematic review of systematic reviews with or without meta-analysis published between 1995 and 2015 was performed. Three independent reviewers assessed for article selection, quality and data extraction.

RESULTS

Thirteen (13) systematic reviews/meta-analysis were included for qualitative synthesis. A reduction (0.23 to 1.03 percentage points) in the levels of HbA1c at 3 months after periodontal intervention was found. This reduction was statistically significant in 10/12 meta-analysis. One review with sufficiently large samples found a non-significant reduction (-0.014 percentage points; 95% CI -0.18 to 0.16; p = 0.87). Only three studies separated the use of adjunctive antibiotics and found a reduction of 0.36 percentage points but the difference was not statistically significant.

CONCLUSIONS

Highly heterogeneous short-term studies with small sample size suggest that periodontal treatment could help improve glycaemic control at 3 months in patients with type 2 diabetes and periodontitis. However, longer term studies having sufficient sample size do not provide evidence that periodontal therapy improves glycaemic control in these patients.

Factors associated with the clinical response to nonsurgical periodontal therapy in people with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a growing health problem worldwide. People with T2DM are at risk of experiencing periodontitis and likely require treatment. Using data from the national multicenter Diabetes and Periodontal Therapy Trial (DPTT), the authors assessed patient-based characteristics associated with the clinical response to nonsurgical therapy.

METHODS

The DPTT investigators randomly assigned adults with T2DM (hemoglobin A1c [HbA1c] ≥ 7 percent and < 9 percent) and moderate to advanced periodontitis to receive immediate or delayed therapy (scaling and root planing, oral hygiene instruction, chlorhexidine rinse). The investigators assessed probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), and medical conditions at baseline, three months and six months. Six-month changes in mean PD, CAL and BOP defined the treatment response. Complete data were available for 473 of 514 DPTT participants. The authors used multiple regression models to evaluate participant-level factors associated with the response.

RESULTS

More severe baseline PD, CAL and BOP were associated with greater improvements in these same measurements (P < .0001). Hispanic participants experienced greater improvements in PD and CAL than did non-Hispanic participants (P < .0001). Obese participants (those with a body mass index > 30 kilograms per square meter) experienced greater reductions in PD and BOP than did participants who were not obese (P < .001). Age, sex, HbA1c values, diabetes duration, and smoking were not associated with change in any outcome (P > .1).

CONCLUSIONS

In patients with T2DM, baseline disease severity was associated with the clinical response to nonsurgical periodontal therapy. Body mass index and Hispanic ethnicity-but not glycemic control, diabetes duration or smoking-also may be useful in predicting clinical changes in this population.

Amoxicillin Plus Metronidazole Therapy for Patients with Periodontitis and Type 2 Diabetes

The aim of this study was to assess the changes occurring in subgingival biofilm composition and in the periodontal clinical parameters of subjects with periodontitis and type 2 diabetes mellitus (DM) treated by means of scaling and root planing (SRP) only or combined with systemic metronidazole (MTZ) and amoxicillin (AMX). Fifty-eight subjects were randomly assigned to receive SRP only ( n = 29) or with MTZ (400 mg/thrice a day [TID]) and AMX (500 mg/TID) ( n = 29) for 14 d. Six subgingival plaque samples/subject were analyzed by checkerboard DNA–DNA hybridization for 40 bacterial species at baseline and 3 mo, 1 y, and 2 y posttherapy. At 2 y posttherapy, the antibiotic-treated group harbored lower mean proportions (5.5%) of red complex pathogens than the control group (12.1%) ( P < 0.05). The proportions of the Actinomyces species remained stable in the antibiotic group but showed a statistically significant reduction in the control group from 1 to 2 y in subjects achieving a low risk clinical profile for future disease progression (i.e., ≤4 sites with probing depth [PD] ≥5 mm). The test group also had a lower mean number of sites with PD ≥5 mm (3.5 ± 3.4) and a higher percentage of subjects reaching the low risk clinical profile (76%) than the control group (14.7 ± 13.1 and 22%, respectively) ( P < 0.05) at 2 y posttreatment. MTZ + AMX intake was the only significant predictor of subjects achieving the low risk at 2 y (odds ratio, 20.9; P = 0.0000). In conclusion, the results of this study showed that the adjunctive use of MTZ + AMX improves the microbiological and clinical outcomes of SRP in the treatment of subjects with generalized chronic periodontitis and type 2 DM up to 2 y ( ClinicalTrials.gov NCT02135952).

Management of diabolical diabetes mellitus and periodontitis nexus: Are we doing enough?

Periodontitis is the commonest oral disease affecting population worldwide. This disease is notorious for the devastation of tooth supporting structures, ensuing in the loss of dentition. The etiology for this disease is bacterial biofilm, which accumulates on the teeth as dental plaque. In addition to the biofilm microorganisms, other factors such as environmental, systemic and genetic are also responsible in progression of periodontitis. Diabetes mellitus (DM) is metabolic disorder which has an impact on the global health. DM plays a crucial role in the pathogenesis of periodontitis. Periodontitis is declared as the “sixth” major complication of DM. Evidence based literature has depicted an enhanced incidence and severity of periodontitis in subjects with DM. A “two way” relationship has been purported between periodontitis and DM. Mutual management of both conditions is necessary. Periodontal therapy (PT) may assist to diminish the progression of DM and improve glycemic control. Various advanced technological facilities may be utilized for the purpose of patient education and disease management. The present paper clarifies the etio-pathogenesis of periodontitis, establishing it as a complication of DM and elaborating the various mechanisms involved in the pathogenesis. The role of PT in amelioration of DM and application of digital communication will be discussed. Overall, it is judicious to create an increased patient cognizance of the periodontitis-DM relationship. Conjunctive efforts must be undertaken by the medical and oral health care professionals for the management of periodontitis affected DM patients.

Treatment of periodontal disease for glycaemic control in people with diabetes mellitus

BACKGROUND

Glycaemic control is a key issue in the care of people with diabetes mellitus (DM). Periodontal disease is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontal disease. This review updates the previous version published in 2010.

OBJECTIVES

The objective is to investigate the effect of periodontal therapy on glycaemic control in people with diabetes mellitus.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 31 December 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2014, Issue 11), MEDLINE via OVID (1946 to 31 December 2014), EMBASE via OVID (1980 to 31 December 2014), LILACS via BIREME (1982 to 31 December 2014), and CINAHL via EBSCO (1937 to 31 December 2014). ZETOC (1993 to 31 December 2014) and Web of Knowledge (1990 to 31 December 2014) were searched for conference proceedings. Additionally, two periodontology journals were handsearched for completeness, Annals of Periodontology (1996 to 2003) and Periodontology 2000 (1993 to 2003). We searched the US National Institutes of Health Trials Registry (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 DM (T1DM/T2DM) with a diagnosis of periodontitis. Interventions included periodontal treatments such as mechanical debridement, surgical treatment and antimicrobial therapy. Two broad comparisons were proposed:1. periodontal therapy versus no active intervention/usual care;2. periodontal therapy versus alternative periodontal therapy.

DATA COLLECTION AND ANALYSIS

For this review update, at least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials and assessed included trials for risk of bias.Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c).Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing (BOP), clinical attachment level (CAL), gingival index (GI), plaque index (PI) and probing pocket depth (PPD)), cost implications and diabetic complications.

MAIN RESULTS

We included 35 studies (including seven from the previous version of the review), which included 2565 participants in total. All studies used a parallel RCT design, and 33 studies (94%) only targeted T2DM patients. There was variation between studies with regards to included age groups (ages 18 to 80), duration of follow-up (3 to 12 months), use of antidiabetic therapy, and included participants' baseline HbA1c levels (from 5.5% to 13.1%).We assessed 29 studies (83%) as being at high risk of bias, two studies (6%) as being at low risk of bias, and four studies (11%) as unclear. Thirty-four of the studies provided data suitable for analysis under one or both of the two comparisons.Comparison 1: low quality evidence from 14 studies (1499 participants) comparing periodontal therapy with no active intervention/usual care demonstrated that mean HbA1c was 0.29% lower (95% confidence interval (CI) 0.48% to 0.10% lower) 3 to 4 months post-treatment, and 0.02% lower after 6 months (five studies, 826 participants; 95% CI 0.20% lower to 0.16% higher).Comparison 2: 21 studies (920 participants) compared different periodontal therapies with each other. There was only very low quality evidence for the multiple head-to-head comparisons, the majority of which were unsuitable to be pooled, and provided no clear evidence of a benefit for one periodontal intervention over another. We were able to pool the specific comparison between scaling and root planing (SRP) plus antimicrobial versus SRP and there was no consistent evidence that the addition of antimicrobials to SRP was of any benefit to delivering SRP alone (mean HbA1c 0.00% lower: 12 studies, 450 participants; 95% CI 0.22% lower to 0.22% higher) at 3-4 months post-treatment, or after 6 months (mean HbA1c 0.04% lower: five studies, 206 patients; 95% CI 0.41% lower to 0.32% higher).Less than half of the studies measured adverse effects. The evidence was insufficient to conclude whether any of the treatments were associated with harm. No other patient-reported outcomes (e.g. quality of life) were measured by the included studies, and neither were cost implications or diabetic complications.Studies showed varying degrees of success with regards to achieving periodontal health, with some showing high levels of residual inflammation following treatment. Statistically significant improvements were shown for all periodontal indices (BOP, CAL, GI, PI and PPD) at 3-4 and 6 months in comparison 1; however, this was less clear for individual comparisons within the broad category of comparison 2.

AUTHORS' CONCLUSIONS

There is low quality evidence that the treatment of periodontal disease by SRP does improve glycaemic control in people with diabetes, with a mean percentage reduction in HbA1c of 0.29% at 3-4 months; however, there is insufficient evidence to demonstrate that this is maintained after 4 months.There was no evidence to support that one periodontal therapy was more effective than another in improving glycaemic control in people with diabetes mellitus.In clinical practice, ongoing professional periodontal treatment will be required to maintain clinical improvements beyond 6 months. Further research is required to determine whether adjunctive drug therapies should be used with periodontal treatment. Future RCTs should evaluate this, provide longer follow-up periods, and consider the inclusion of a third 'no treatment' control arm.Larger, well conducted and clearly reported studies are needed in order to understand the potential of periodontal treatment to improve glycaemic control among people with diabetes mellitus. In addition, it will be important in future studies that the intervention is effective in reducing periodontal inflammation and maintaining it at lowered levels throughout the period of observation.

A practical approach to evidence-based dentistry: III: how to appraise and use an article about therapy

BACKGROUND AND OVERVIEW

Dental practitioners spend most of their time administering treatments. To ensure that their clinical decisions are informed by the best available evidence, dental practitioners need to be skilled in critically appraising studies addressing therapy issues. Randomized controlled trials offer the optimal study design to inform decisions regarding therapy. The critical appraisal of randomized controlled trials involves assessing the risk of bias, results, and applicability. In this article, the authors present these concepts and provide guidance for this type of appraisal.

PRACTICAL IMPLICATIONS

Dentists who wish to inform their clinical decisions regarding therapy and prevention questions can use these guidelines to decide what type of studies to search, define the specific question of interest to search efficiently for these studies, and critically appraise an article about therapy or prevention.

Effects of periodontal therapy on metabolic control in patients with type 2 diabetes mellitus and periodontal disease: a meta-analysis

Epidemiologic studies have reported increased incidence, prevalence and acuity of periodontitis in adults with diabetes and some have also suggested that treating periodontal disease may improve glycemic control in diabetic patients. This meta-analysis was conducted to evaluate the effects of different periodontal therapies on metabolic control in patients with type 2 diabetes mellitus (T2DM) and periodontal disease. We searched the Medline, EMBASE and Cochrane Library (Central) databases up to January 2014 for relevant studies pertaining to periodontal treatments and glycemic control in adults with T2DM. The search terms were periodontal treatment/periodontal therapy, diabetes/diabetes mellitus, periodontitis/periodontal and glycemic control. The primary outcome measure taken from the included studies was glycated hemoglobin (HbA1c). We compared differences in patients' pre- and post-intervention HbA1c results between a treatment group receiving scaling and root planing (SRP) combined with administration of oral doxycycline (n=71) and controls receiving SRP alone or SRP plus placebo (n=72). Meta-analysis was performed using Comprehensive Meta Analysis software. Nineteen randomized controlled trials (RCTs) were identified. Four trials involving a total of 143 patients with T2DM and periodontal disease were determined to be eligible for analysis. Data of 1 study were not retained for meta-analysis because HbA1c results were recorded as median with IQR. Meta-analysis of the included 3 studies revealed no significant differences in HbA1c results between the periodontal treatment group (n=71) and control group (n=72) (HbA1c SMD=-0.238, 95% CI=-0.616 to 0.140; P=0.217). Systemic doxycycline added to SRP does not significantly improve metabolic control in patients with T2DM and chronic periodontitis. Current evidence is insufficient to support a significant association between periodontal therapy and metabolic control in this patient population. However, evidence suggests that periodontal therapy itself improves metabolic control and reinforces that T2DM is a risk factor for periodontitis.

Metronidazole and amoxicillin as adjuncts to scaling and root planing for the treatment of type 2 diabetic subjects with periodontitis: 1-year outcomes of a randomized placebo-controlled clinical trial

AIM

To evaluate the clinical and microbiological effects of the use of metronidazole (MTZ) + amoxicillin (AMX) as adjuncts to scaling and root planing (SRP) for the treatment of chronic periodontitis (ChP) in type 2 diabetic subjects.

MATERIAL AND METHODS

Fifty-eight type 2 diabetic subjects (n = 29/group) with generalized ChP were randomly assigned to receive SRP alone or with MTZ [400 mg/thrice a day (TID)]+AMX (500 mg/TID) for 14 days. Subgingival biofilm samples were analyzed by qPCR for the presence of seven periodontal pathogens. Subjects were monitored at baseline, 3, 6 and 12 months post-therapies.

RESULTS

The group receiving SRP+MTZ+AMX presented greater mean probing depth (PD) reduction and clinical attachment gain, a lower number of sites with PD ≥5 mm (primary outcome variable) and a reduced number of subjects with ≥9 of these residual pockets than the control group at 1-year post-therapy (p < 0.05). The antibiotic-treated group also presented reduced levels and greater decreases of the three red complex species, Eubacterium nodatum and Prevotella intermedia, compared to the control group at 1 year (p < 0.05).

CONCLUSIONS

The adjunctive use of MTZ+AMX significantly improved the clinical and microbiological outcomes of SRP in the treatment of type 2 diabetic subjects with ChP.

4-methoxycarbonyl curcumin: a unique inhibitor of both inflammatory mediators and periodontal inflammation

Chronic inflammatory diseases such as periodontitis have been associated with increased risk for various medical conditions including diabetes and cardiovascular disease. Endotoxin (lipopolysaccharide, LPS), derived from gram-negative periodonto-pathogens, can induce the local accumulation of mononuclear cells in the inflammatory lesion, increasing proinflammatory cytokines and matrix metalloproteinases (MMPs). This ultimately results in the destruction of periodontal connective tissues including alveolar bone. Curcumin is the principal dyestuff in the popular Indian spice turmeric and has significant regulatory effects on inflammatory mediators but is characterized by poor solubility and low bioactivity. Recently, we developed a series of chemically modified curcumins (CMCs) with increased solubility and zinc-binding activity, while retaining, or further enhancing, their therapeutic effects. In the current study, we demonstrate that a novel CMC (CMC 2.5: 4-methoxycarbonyl curcumin) has significant inhibitory effects, better than the parent compound curcumin, on proinflammatory cytokines and MMPs in in vitro, in cell culture, and in an animal model of periodontal inflammation. The therapeutic potential of CMC 2.5 and its congeners may help to prevent tissue damage during various chronic inflammatory diseases including periodontitis and may reduce the risks of systemic diseases associated with this local disorder.

Routine prophylaxes every 3 months improves chronic periodontitis status in type 2 diabetes

BACKGROUND

Periodontitis and type 2 diabetes mellitus (T2DM) are major health problems, especially in low-income populations with little access to dental care. Low-cost models for treatment of periodontal disease have not been tested in controlled studies in low-income populations. Dental prophylaxis, which includes removal of supragingival calculus and plaque, has been shown to arrest the progression of periodontitis. A controlled clinical trial was conducted to determine the effect of dental prophylaxis on periodontitis in T2DM.

METHODS

Twenty-six patients with T2DM and chronic periodontitis (CP) and 26 without T2DM with CP were selected. Periodontal probing depth (PD), gingival bleeding on probing (BOP), clinical attachment level (CAL), and surfaces with plaque were recorded at baseline and 3, 6, and 9 months after initial treatment. All the participants received instructions on oral hygiene and one session of dental prophylaxis at baseline and every 3 months. Glycated hemoglobin (HbA1c) levels were measured at baseline and every 3 months in patients with T2DM.

RESULTS

A significant improvement of PD, BOP, and sites with plaque was observed 3 months after treatment in patients with T2DM (P = 0.001). In controls, mean PD significantly improved after 6 months compared with baseline (P = 0.001). No significant improvement of CAL occurred in either group. No significant differences in periodontal parameters between the groups were detected, and no participant showed progression of CP during the 9-month study period. Dental prophylaxis did not influence HbA1c levels, and no association among HbA1c concentration, pretreatment metabolic status, and severity of CP was found.

CONCLUSION

Routine prophylaxes every 3 months significantly improve periodontal health and prevent progression of CP in both poorly controlled and well-controlled patients with T2DM.