Clinical efficacy of scaling and root planing with and without metronidazole on glycemic control: three-arm randomized controlled trial

Efficacy of localized sustained-release drugs in periodontitis and comorbid diabetes: A systematic review and meta-analysis

Our meta-analysis aimed to evaluate the efficacy of localized sustained-release drugs in periodontitis and comorbid diabetes. PubMed, Cochrane Library, Embase, and Web of Science were comprehensively searched until 4 December 2024, and 10 randomized controlled trials (RCTs) were included. The results indicated that, compared to the control group, localized sustained-release drugs significantly reduced probing depth (PD) (SMD = -0.77, 95% confidence interval [CI] (-1.37, -0.16)) but did not reduce clinical attachment loss (CAL) (SMD = -0.18, 95% CI (-0.60, 0.23)), sites with glycated hemoglobin (HbA1c) (SMD = 0.03, 95% CI (-0.38, 0.43)), plaque index (SMD = -0.37, 95% CI (-0.80, 0.06)), sites with bleeding on probing (BOP) (SMD = -0.26, 95% CI (-0.68, 0.16)), and gingival index (SMD = 0.07, 95% CI (-0.30, 0.44)). Subgroup analysis by different drugs elicited that, compared to the control treatment, chlorhexidine was effective in reducing BOP% (SMD = -0.55, 95% CI (-0.90, -0.19)). Our meta-analysis finds that the efficacy of localized sustained-release drugs in periodontitis and comorbid diabetes is limited.

The role of periodontal treatment on the reduction of hemoglobinA1c, comparing with existing medication therapy: a systematic review and meta-analysis

Background

Diabetes mellitus (DM) is linked to complications such as retinopathy, nephropathy, neuropathy, and cardiovascular disease, impacting patient quality of life and increasing healthcare costs. Periodontal disease, more prevalent in diabetic patients, is associated with worsened glycemic control and systemic inflammation, suggesting a possible bidirectional relationship. While some studies indicate periodontal treatment may improve glycemic control and reduce inflammation, overall evidence is inconsistent. It remains unclear if periodontal therapy reliably enhances diabetes outcomes or if certain patient subgroups benefit more than others.

Objective

To systematically review randomized controlled trials (RCTs) evaluating the effects of periodontal therapy on glycemic control (HbA1c) and systemic inflammation (CRP) in type 1 and type 2 diabetes patients.

Methods

Following PRISMA guidelines, a comprehensive PubMed search identified RCTs comparing HbA1c and CRP outcomes in diabetic patients with periodontal therapy versus controls. Inclusion criteria required at least three to six months of follow-up. Meta-analyses using a random effects model were conducted for HbA1c and CRP changes.

Results

Eleven studies met inclusion criteria. Meta-analyses showed significant reductions in HbA1c at three months (-0.64; CI95%=-0.96 to -0.32; I2 = 73%) and six months (-0.33; CI95%=-0.65 to -0.01; I2 = 12%). CRP also declined significantly, indicating an improvement in systemic inflammation.

Conclusion

Periodontal therapy appears to significantly reduce HbA1c and CRP levels over short-term periods in diabetic patients, suggesting potential as a beneficial adjunct to diabetes management. These findings support incorporating periodontal care into diabetes treatment to reduce systemic inflammation and potentially lower healthcare costs. Future long-term, standardized RCTs are needed to confirm sustained effects and investigate responses in diverse patient populations.

The Efficacy of Topical or Systemic Antibiotics as Adjuvants to Non-Surgical Periodontal Treatment in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Periodontitis and diabetes mellitus (DM) exhibit a bidirectional relationship and are globally significant systemic chronic conditions. The utilization of antibiotics alongside non-surgical periodontal treatment (NSPT) has been a subject of investigation in numerous clinical studies involving human subjects. Thus, the objective of this systematic review is to address the following question: "What is the efficacy of scaling and root planing (SRP) associated with antimicrobials in patients with type 2 DM and periodontitis?". Methods: A systematic review of the literature was conducted encompassing databases such as MEDLINE/PubMed, Scopus, and Web of Science up to July 2024. Additionally, alerts were configured to capture studies published from the initial search until manuscript submission. Randomized clinical trials assessing clinical periodontal parameters in DM patients undergoing SRP and receiving either topical or systemic antibiotics were compared against a control group (SRP only). Two investigators independently screened articles, extracted data, and evaluated their quality. The selection process, study characteristics, risk of bias, impact of antibiotics on clinical parameters, and certainty of evidence were elucidated in both textual and tabular formats. Meta-analysis was performed separately with forest plots generated for treatment modalities, period of evaluation, and type of antibiotics used. Results: Following the analysis of abstracts and full articles, a total of 30 randomized clinical trials were incorporated into this review, comprising 9 studies on the association of topical antibiotics and 21 studies on systemic antibiotic administration. The principal periodontal parameters assessed included probing pocket depth (PPD), clinical attachment level (CAL), plaque index (PI), and bleeding on probing (BoP). Conclusions: Analysis of the results led to the conclusion that adjunctive periodontal treatment with either topical or systemic antibiotics confers subtle clinical benefits. Nevertheless, owing to the heightened emergence of resistant bacteria and potential side effects, the use of antibiotic therapy in periodontal treatment should be judiciously administered.

Periodontitis and non-communicable diseases in a Brazilian population, a cross-sectional study, Vila Velha-ES, Brazil

BACKGROUND

The objective of this study was to examine the hypothesis that periodontal disease is associated with chronic non-communicable diseases.

METHODS

In this cross-sectional study, we evaluated the periodontal health condition of the population, based on the community periodontal index, as well as the number of missing teeth and the presence of systemic health conditions. We quantified the association between oral health and the presence of chronic diseases using simple logistic regression, adjusting for confounding factors including age, smoking, and overweight.

RESULTS

The study population consisted of 334 volunteers, aged between 19 and 81 years. In patients over 45 years old, periodontal disease was found to be significantly associated with hypertension and diabetes. Furthermore, in female patients, periodontal disease was significantly associated with hypertension, diabetes, and cancer.

CONCLUSION

Our findings indicate that periodontal disease is positively and significantly associated with both arterial hypertension and diabetes, independent of potential confounding factors.

Oral Health Education in Patients with Diabetes: A Systematic Review

Diabetes is known as a "silent epidemic" and is a public health problem that accounts for 9% of all deaths worldwide. The prevention of diabetes is a significant challenge, as its prevalence and incidence are both increasing rapidly. According to the World Health Organization (WHO), education is the cornerstone of diabetes treatment. Since the severity of oral diseases is significantly higher in diabetic patients, this systematic review aims to highlight the oral care of diabetic patients as a priority for glycemic control and the importance of education for diabetic patients' oral health. We evaluated 20 clinical studies and 15 meta-analyses from PubMed and Google Scholar over the last five years. Their main themes are the direct relationship between diabetes and oral health, especially periodontitis, and the necessity of education and behaviors that can lead to a better quality of life. Our analysis indicated that good oral health is a critical factor of glycemic control in diabetic patients and can be enhanced by targeted educational programs, backed by long-term medical and dental follow-up. Healthcare personnel should be encouraged to develop their knowledge of oral health in relation to the disease so that behaviors can be adopted to improve patients' quality of life. Telemedicine could also contribute to patient education and self-management of the disease.

Systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of non-surgical periodontal treatment in patients with concurrent systemic conditions

OBJECTIVE

To conduct a systematic review of the published scientific evidence to evaluate the efficacy of nonsurgical periodontal therapy (NSPT) in treating periodontitis in patients with concurrent systemic conditions (diabetes, CVD, erectile dysfunction, chronic kidney disease, rheumatoid arthritis, polycystic ovarian syndrome, obesity, pregnancy). We hypothesised that NSPT results in better periodontal outcomes when compared to untreated controls after follow-up.

MATERIALS AND METHODS

A systematic search (PUBMED/EMBASE) was conducted from 1995 to 2023 to identify randomised controlled trials (RCTs) with a minimum follow-up of 3 months. The primary outcome was the difference in mean probing depth (PD), and the secondary outcomes were mean clinical attachment loss (CAL), percentage of sites with PD ≤ 3 mm (%PD ≤ 3 mm) and percentage of sites with bleeding on probing (%BOP) between the treated and untreated control group in patients with comorbidities.

RESULTS

The electronic search resulted in 2,403 hits. After removing duplicates, 1,565 titles and abstracts were screened according to the eligibility criteria, resulting in 126 articles for full-text screening. Following this, 44 studies were analysed. Restricting to studies with low bias or some concerns, NSPT group demonstrated a 0.55 mm lower mean PD (95%CI: -0.69; -0.41) after 3 months compared to the control group.

CONCLUSION

Compared to the untreated controls, NSPT notably reduced mean PD, mean CAL, and %BOP while increasing %PD ≤ 3 mm in patients with concurrent systemic conditions. These findings suggest that NSPT is also an effective procedure in managing periodontitis in patients with concurrent systemic conditions.

TRIAL REGISTRATION

This systematic review was registered under the protocol registration number CRD42021241517/PROSPERO.

Diabetes, periodontitis, and cardiovascular disease: towards equity in diabetes care

Type 2 diabetes and its associated cardiovascular risk is an escalating epidemic that represents a significant public health burden due to increased morbidity and mortality, disproportionately affecting disadvantaged communities. Poor glycaemic control exacerbates this burden by increasing retinal, renal, and cardiac damage and raising healthcare costs. This predicament underscores the urgent need for research into cost-effective approaches to preventing diabetes complications. An important but often overlooked strategy to improve metabolic control in diabetic patients is the treatment of periodontitis. Our aim is to assess whether the inclusion of periodontitis treatment in diabetes management strategies can effectively improve metabolic control, and to advocate for its inclusion from an equity perspective. We conducted a comprehensive review of the literature from 2000 to 2023. We analyzed the pathophysiological links between periodontitis, diabetes, and atherosclerotic cardiovascular disease, all of which have inflammation as a central component. We also examined the inequalities in health care spending in this context. Our findings suggest that incorporating routine screening and treatment of periodontitis into national health programs, with coordinated efforts between physicians and dentists, is a cost-effective measure to improve metabolic control, reduce complications and improve the overall quality of life of people with diabetes.

Systemic antibiotics adjuvants to scaling and root planing in type 2 diabetic and periodontitis individuals: Systematic review with network meta-analysis

Targeting inflammatory pathways is considered a common strategy to control type 2 diabetes (T2D) and periodontitis. This overview was to validate systemic antibiotics as an adjuvant to scaling and root planing (SRP) for the treatments of periodontal patients with T2D. Literature searches were conducted using Web of Science, PubMed, Cochrane, and EMBASE. Randomized trials comparing SRP and systemic antibiotics on glycated hemoglobin (HbA1c) and probing pocket depth (PPD) in adults with T2D and periodontitis were analyzed using network meta-analysis and meta-regression. At 3-month postintervention, meta-analyses of 16 studies revealed that SRP and SRP plus systemic antibiotics (SRPa) had similar significant effects in reducing HbA1c levels of - 0.72% and - 0.96% respectively. While SRP and SRPa also, respectively, reduced PPD of - 0.67 and - 0.89 mm, SRPa showed a better reduction than SRP. At 6-month postintervention, meta-analyses of 7 trials revealed that only SRP was effective in reducing HbA1c levels (-0.29%) but not SRPa. Although both SRP and SRPa still significantly reduced PPD by - 0.56 and - 0.81 mm, respectively, there was no difference between them. The current overview suggested that routine SRP alone is highly recommended for patients with T2D and periodontitis, since systemic antibiotics as an adjuvant provide a rather short-term effect.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Advances in novel therapeutic approaches for periodontal diseases

Periodontal diseases are pathological processes resulting from infections and inflammation affecting the periodontium or the tissue surrounding and supporting the teeth. Pathogenic bacteria living in complex biofilms initiate and perpetuate this disease in susceptible hosts. In some cases, broad-spectrum antibiotic therapy has been a treatment of choice to control bacterial infection. However, increasing antibiotic resistance among periodontal pathogens has become a significant challenge when treating periodontal diseases. Thanks to the improved understanding of the pathogenesis of periodontal disease, which involves the host immune response, and the importance of the human microbiome, the primary goal of periodontal therapy has shifted, in recent years, to the restoration of homeostasis in oral microbiota and its harmonious balance with the host periodontal tissues. This shift in therapeutic goals and the drug resistance challenge call for alternative approaches to antibiotic therapy that indiscriminately eliminate harmful or beneficial bacteria. In this review, we summarize the recent advancement of alternative methods and new compounds that offer promising potential for the treatment and prevention of periodontal disease. Agents that target biofilm formation, bacterial quorum-sensing systems and other virulence factors have been reviewed. New and exciting microbiome approaches, such as oral microbiota replacement therapy and probiotic therapy for periodontal disease, are also discussed.

Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline

BACKGROUND

The recently published clinical practice guideline (CPG) for the treatment of periodontitis in stages I-III provided evidence-based recommendations for the treatment of periodontitis patients, defined according to the 2018 classification. Stage IV periodontitis shares the severity and complexity characteristics of stage III periodontitis, but includes the anatomical and functional sequelae of tooth and periodontal attachment loss (tooth flaring and drifting, bite collapse, etc.), which require additional interventions following completion of active periodontal therapy.

AIM

To develop an S3 Level CPG for the treatment of stage IV periodontitis, focusing on the implementation of inter-disciplinary treatment approaches required to treat/rehabilitate patients following associated sequelae and tooth loss.

MATERIALS AND METHODS

This S3 Level CPG was developed by the European Federation of Periodontology (EFP), following methodological guidance from the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process. A rigorous and transparent process included synthesis of relevant research in 13 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and a structured consensus process with leading experts and a broad base of stakeholders.

RESULTS

The S3 Level CPG for the treatment of stage IV periodontitis culminated in recommendations for different interventions, including orthodontic tooth movement, tooth splinting, occlusal adjustment, tooth- or implant-supported fixed or removable dental prostheses and supportive periodontal care. Prior to treatment planning, it is critically important to undertake a definitive and comprehensive diagnosis and case evaluation, obtain relevant patient information, and engage in frequent re-evaluations during and after treatment. The periodontal component of therapy should follow the CPG for the treatment of periodontitis in stages I-III.

CONCLUSIONS

The present S3 Level CPG informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat patients with stage IV periodontitis and to maintain a healthy dentition over lifetime, according to the available evidence at the time of publication.

Treatment of periodontitis for glycaemic control in people with diabetes mellitus

BACKGROUND

Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis.  Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non-surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care.  OBJECTIVES: To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis.

SEARCH METHODS

An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies.  SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin).

DATA COLLECTION AND ANALYSIS

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. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications.

MAIN RESULTS

We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel-RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care.  We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate-certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) -0.59% to -0.28%; -6.4 mmol/mol to -3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI -0.52% to -0.08%; -5.7 mmol/mol to -0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI -0.55% to -0.45%; -6.0 mmol/mol to -4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies.

AUTHORS' CONCLUSIONS

Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate-certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review.

Classic vs. Novel Antibacterial Approaches for Eradicating Dental Biofilm as Adjunct to Periodontal Debridement: An Evidence-Based Overview

Periodontitis is a multifactorial chronic inflammatory disease that affects tooth-supporting soft/hard tissues of the dentition. The dental plaque biofilm is considered as a primary etiological factor in susceptible patients; however, other factors contribute to progression, such as diabetes and smoking. Current management utilizes mechanical biofilm removal as the gold standard of treatment. Antibacterial agents might be indicated in certain conditions as an adjunct to this mechanical approach. However, in view of the growing concern about bacterial resistance, alternative approaches have been investigated. Currently, a range of antimicrobial agents and protocols have been used in clinical management, but these remain largely non-validated. This review aimed to evaluate the efficacy of adjunctive antibiotic use in periodontal management and to compare them to recently suggested alternatives. Evidence from in vitro, observational and clinical trial studies suggests efficacy in the use of adjunctive antimicrobials in patients with grade C periodontitis of young age or where the associated risk factors are inconsistent with the amount of bone loss present. Meanwhile, alternative approaches such as photodynamic therapy, bacteriophage therapy and probiotics showed limited supportive evidence, and more studies are warranted to validate their efficiency.

Effects of Metronidazole as an Adjunct to Non-Surgical Periodontal Therapy on Insulin Resistance in Type 2 Diabetics

Treating periodontitis with metronidazole (MET) as an adjunct to scaling root planing (SRP) is suggested to have inconsistent effects on insulin resistance (IR) in type 2 diabetes mellitus (T2DM). This paper will present the effects of MET, in addition to SRP, on the homeostatis model assessment of IR (HOMA-IR). A three-arm clinical trial was conducted and analyses were performed on T2DM participants with periodontitis (n = 74) who completed follow-up visits at 3 and 6 months after the intervention. The observed between-group and within-group mean changes in IR were found using ANOVA with repeated measures, followed by a post-hoc analysis, and a p-value of ≤0.05 was considered significant. Between-group analyses showed no difference in the HOMA-IR at 3 months, but at 6 months the difference was significant (p = 0.046). Within-group analyses showed that the HOMA-IR was significantly reduced in both test groups (p ≤ 0.05) over the period of time. Adjunct use of MET may result in a sudden short-term lowering of the HOMA-IR level within 3 months that may not be retained over 6 months when compared to the sustained lowering of the HOMA-IR levels in T2DM when intervened with SRP without MET.