Periodontal disease in juvenile and adult diabetic patients: a review of the literature

Periodontal Disease and Other Adverse Health Outcomes Share Risk Factors, including Dietary Factors and Vitamin D Status

For nearly a century, researchers have associated periodontal disease (PD) with risks of other adverse health outcomes such as cardiovascular disease, diabetes mellitus, and respiratory diseases, as well as adverse pregnancy outcomes. Those findings have led to the hypothesis that PD causes those adverse health outcomes either by increasing systemic inflammation or by the action of periodontopathic bacteria. However, experiments largely failed to support that hypothesis. Instead, the association is casual, not causal, and is due to shared underlying modifiable risk factors, including smoking, diet, obesity, low levels of physical activity, and low vitamin D status. Diabetes mellitus is also considered a risk factor for PD, whereas red and processed meat are the most important dietary risk factors for diabetes. Because PD generally develops before other adverse health outcomes, a diagnosis of PD can alert patients that they could reduce the risk of adverse health outcomes with lifestyle changes. In addition, type 2 diabetes mellitus can often be reversed rapidly by adopting an anti-inflammatory, nonhyperinsulinemic diet that emphasizes healthful, whole plant-based foods. This review describes the evidence that proinflammatory and prohyperinsulinemia diets and low vitamin D status are important risk factors for PD and other adverse health outcomes. We also make recommendations regarding dietary patterns, food groups, and serum 25-hydroxyvitamin D concentrations. Oral health professionals should routinely inform patients with PD that they could reduce their risk of severe PD as well as the risks of many other adverse health outcomes by making appropriate lifestyle changes.

Association between metabolic control and oral health in children with type 1 diabetes mellitus

Background

Type 1 diabetes mellitus is the most common chronic disease and can be reflected in the oral cavity. The aim of this study was to analyze the impact of metabolic control on saliva, dental caries, dental plaque, gingival inflammation, and cariogenic bacteria in saliva.

Methods

A case–control epidemiologic study was performed on children with type 1 diabetes (ages 10–15 years) separated into two groups: 34 children with good metabolic control of glycated hemoglobin (HbA1c < 7.5%) and 46 children with poor metabolic control of glycated hemoglobin (HbA1c > 7.5%). Oral status was assessed using the Decay, Missing, and Filled Teeth index for permanent teeth (DMFT), plaque index and gingival index. The stimulated salivary flow rate was measured, and the colonies of Streptococcus mutans and Lactobacillus in saliva were determined. The observed children answered questions related to their frequency of brushing habits, dental visits and parents’ education. Mann–Whitney U Test, Chi-Square test and Fisher’s exact test were used in the statistical analyses. The significance level was set at p < 0.05.

Results

The children with diabetes with poor metabolic control had significantly higher values of the DMFT index, plaque index, and gingival index, more colonies, and a higher risk of Streptococcus mutans and Lactobacillus than the children with diabetes with good metabolic control (p < 0.001). The level of metabolic control of diabetes had no influence on salivary flow rates (p > 0.05). The majority of both groups with good and poor metabolic control brushed their teeth once per day, and they visited the dentist only when necessary (61.3%). However, the parents of children in both groups had medium to low levels of education, without any significant difference between groups (p > 0.05).

Conclusion

The results indicate that children with diabetes have a lower level of oral hygiene and are potentially to dental caries and periodontal diseases, mainly when their metabolic disorder is uncontrolled.

Periodontal Disease in Type 1 Diabetes Mellitus: Influence of Pubertal Stage and Glycemic Control

OBJECTIVE

Though gingivitis is common in children with type 1 diabetes mellitus (T1DM), the overall periodontal health in T1DM during the pubertal stage is less well-characterized. The study was undertaken to explore the possible influence of puberty and metabolic derangement on periodontal health in T1DM.

METHODS

In this cross-sectional study, 110 subjects between 10-18 years with T1DM and 52 healthy siblings of similar age were evaluated for pubertal stage, glycosylated hemoglobin (HbA1c), and periodontal health. Simplified oral hygiene index (OHIS), gingival index (GI), plaque index (PI), bleeding on probing (BOP), and probing depth (PPD) were evaluated at 4 sites per tooth as per 6 Ramfjord index teeth used to assess periodontal disease (PD).

RESULTS

PD not merely gingivitis was significantly higher in T1DM (84/110, 76.36%) than the control group (28/52, 53.8%) (P = .004). Irrespective of pubertal status, children with T1DM had worse GI, PI, BOP, and PPD than nondiabetic subjects, although OHIS was better in diabetes. In both T1DM and nondiabetic subjects, pubertal subjects showed significantly worse OHIS, PPD, BOP, and GI than prepubertal subjects. PD was correlated with pubertal stage, age, and HbA1c, although less strongly with the duration of diabetes. In logistic regression, pubertal stage was a stronger predictor of PD (OR = 14.26) than age (OR = 2.22), and HbA1c (OR = 1.5) rather than the presence of diabetes and its duration.

CONCLUSIONS

Though pubertal status, age, and poor glycemic control rather than the presence of diabetes and its duration are associated with gingivitis and other forms of PD, puberty had a more profound effect in the pathogenesis of PD in T1DM.

Salivary Alkaline Phosphatase as a Noninvasive Marker for Periodontal Disease in Children with Uncontrolled Type 1 Diabetes Mellitus

OBJECTIVE

The aim of this pilot study was to determine whether salivary alkaline phosphatase levels can be a non invasive marker for early inflammatory periodontal disease in children with uncontrolled type 1 diabetes mellitus.

STUDY DESIGN

10 healthy children (group 1), 10 children with recently diagnosed type 1 diabetes mellitus (group 2) and 10 children with type 1 diabetes mellitus for more than 4 years (group 3) were recruited for the study. All three groups were matched for age, gender and socioeconomic status. Periodontal health was assessed by plaque index, gingival index and probing pocket depth. Metabolic status was assessed by glycosylated hemoglobin levels, salivary alkaline phosphatase levels were determined by spectrophotometer. Data was analyzed by Kruskal Wallis ANOVA, Mann-Whitney U test and Spearman's rank correlation method.

RESULTS

Salivary alkaline phosphatase levels correlated significantly with the periodontal parameters in the diabetic group. An increase in salivary alkaline phosphatase levels increased with increased values of gingival index and probing pocket depth. Group 3 showed greater correlation than group 2 and group 1. At p value p<0.05.

CONCLUSION

The glycemic status of the children affects the periodontal disease parameters. Salivary alkaline phosphatase levels could be a useful tool in analyzing periodontal status of children with uncontrolled type I diabetes mellitus.

Periodontal changes in children and adolescents with diabetes: a case-control study

OBJECTIVE

To evaluate the level of oral disease in children and adolescents with diabetes.

RESEARCH DESIGN AND METHODS

Dental caries and periodontal disease were clinically assessed in 182 children and adolescents (6-18 years of age) with diabetes and 160 nondiabetic control subjects.

RESULTS

There were no differences between case and control subjects with respect to dental caries. Children with diabetes had significantly higher plaque and gingival inflammation levels compared with control subjects. The number of teeth with evidence of attachment loss (the hallmark of periodontal disease) was significantly greater in children with diabetes (5.79 +/- 5.34 vs. 1.53 +/- 3.05 in control subjects, unadjusted P < 0.001). When controlling for age, sex, ethnicity, gingival bleeding, and frequency of dental visits, diabetes remained a highly significant correlate of periodontitis, especially in the 12- to 18-year-old subgroup. In the case group, BMI was significantly correlated with destruction of connective tissue attachment and bone, but duration of diabetes and mean HbA(1c) were not.

CONCLUSIONS

Our findings suggest that periodontal destruction can start very early in life in diabetes and becomes more prominent as children become adolescents. Programs designed to promote periodontal disease prevention and treatment should be provided to young patients with diabetes.

Aggressive periodontitis with supernumerary teeth: a retrospective study

BACKGROUND

There are four key studies in the periodontology literature reporting the correlation between supernumerary teeth and aggressive periodontitis. The aim of this study is to detect such a relationship.

METHODS

Patients with supernumerary teeth were identified retrospectively from their orthopantomographs and were invited to the periodontology department for intraoral examination. They were then evaluated for aggressive periodontitis. The number of existing teeth, age, family histories, attachment loss, probing depths, and bleeding on probing scores were recorded.

RESULTS

Of the 5,850 subjects randomly observed among 48,000 patients, only 174 exhibited supernumerary teeth. Of these 174 subjects, only three patients were diagnosed with aggressive periodontitis. One of the patients was also suffering from Fanconi's anemia.

CONCLUSIONS

Despite the similarities (aggressive periodontitis accompanied by supernumerary teeth) in the previous reports, we do not agree with the earlier results. We rather suggest that this association might be a random occurrence, rather than a biological one, although this observation should be further investigated using genetic testing.

Ultrastructural determination of gingival Langerhans cells in alloxan-induced diabetic rats

The ultrastructure of Langerhans cells has not been fully investigated in diabetes-associated gingival tissues. The present study was carried out to investigate the ultrastructure of gingival Langerhans cells in alloxan-induced diabetic rats. Gingival biopsies were obtained from 22 diabetic and 18 control rats. Langerhans cells were observed by transmission electron microscopy (TEM) in the basal layers of healthy oral epithelium. On rare occasions, Langerhans cells were found in the suprabasal layers of the oral epithelium. Langerhans cells in the oral epithelium of diabetic rats were seen in the basal and suprabasal layers. Usually, Langerhans cells had clear cytoplasm and convoluted or indented nuclei and few or no specific granules. The clear cytoplasm contained mitochondria, lysosomes and a small number of rough-surfaced endoplasmic reticulum regions, but it lacked tonofilament. Occasionally, centrioles were also observed in the cytoplasm. The membrane of Langerhans cells had no junctional complexes such as desmosomes. In diabetic rats, Langerhans cell precursors were developed into specific granule-bearing cells. Both Langerhans cells and their granules were more frequent in the gingiva of diabetic rats than in the control group. These data suggest that Langerhans cells play an important role in explaining the pathogenesis and development of diabetic gingivitis.

Oral disorders and chronic systemic diseases in very old adults living in institutions

This study evaluated whether oral disorders were associated with chronic systemic diseases in 532 Canadian adults who are old and very old and living in institutions. A brief oral examination documented tooth retention, caries, and periodontal and gingival health. Medical records provided information about chronic systemic conditions. A history of stroke was associated with a higher experience of caries, a higher ratio of decayed-to-present teeth, and more gingival and periodontal problems. Participants with high blood pressure, osteoporosis, or diabetes were more likely to be edentulous or to have fewer teeth than participants who did not have these conditions. Participants who had arthritis retained more teeth with age. Participants who had more diseases also tended to have poorer gingival or periodontal conditions, fewer teeth, and higher risk of edentulousness. The associations between systemic diseases and more severe oral disorders may be direct or may be mediated by underlying factors such as health behaviors.

Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population

OBJECTIVE

We investigated the association between glycemic control of type 2 diabetes mellitus (type 2 DM) and severe periodontal disease in the US adult population ages 45 years and older.

METHODS

Data on 4343 persons ages 45-90 years from the National Health and Nutrition Examination Study III were analyzed using weighted multivariable logistic regression. Severe periodontal disease was defined as 2 + sites with 6 + mm loss of attachment and at least one site with probing pocket depth of 5 + mm. Individuals with fasting plasma glucose > 126 mg/dL were classified as having diabetes; those with poorly controlled diabetes (PCDM) had glycosylated hemoglobin > 9% and those with better-controlled diabetes (BCDM) had glycosylated hemoglobin <or= 9%. Additional variables evaluated in multivariable modeling included age, ethnicity, education, gender, smoking status, and other factors derived from the interview, medical and dental examination, and laboratory assays.

RESULTS

Individuals with PCDM had a significantly higher prevalence of severe periodontitis than those without diabetes (odds ratio = 2.90; 95% CI: 1.40, 6.03), after controlling for age, education, smoking status, and calculus. For the BCDM subjects, there was a tendency for a higher prevalence of severe periodontitis (odds ratio = 1.56; 95% CI: 0.90, 2.68).

CONCLUSION

These results provide population-based evidence to support an association between poorly controlled type 2 diabetes mellitus and severe periodontitis.

Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

This review evaluates evidence for a bidirectional relationship between diabetes and periodontal diseases. A comprehensive Medline search of the post-1960 English language literature was employed to identify primary research reports of relationships between diabetes and periodontal diseases. Reports included in the review on the adverse effects of diabetes on periodontal health (DM-->PD) were restricted to those comparing periodontal health in subjects with and without diabetes. Review of adverse affects of periodontal infection on glycemic control included reports of periodontal treatment studies and follow-up observational studies in which changes in glycemic control could be assessed. Observational studies reporting DM-->PD provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal diseases in the large majority of reports (supportive evidence in 44/48 total reviewed; 37/41 cross-sectional and 7/7 cohort). Additionally, there were no studies reviewed with superior design features to refute this association. Treatment studies provided direct evidence to support periodontal infection having an adverse, yet modifiable, effect on glycemic control. However, not all investigations reported an improvement in glycemic control after periodontal treatment. Additional evidence to support the effect of severe periodontitis on increased risk for poorer glycemic control comes from 2 follow-up observational studies. The evidence reviewed supports viewing the relationship between diabetes and periodontal diseases as bidirectional. Further rigorous, systematic study is warranted to establish that treating periodontal infections can be influential in contributing to glycemic control management and possibly to the reduction of the burden of complications of diabetes mellitus.

Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia

Evidence is increasing that oral health has important impacts on systemic health. This paper presents data from the third National Health and Nutrition Examination Survey (NHANES III) describing the prevalence of dental caries and periodontal diseases in the older adult population. It then evaluates published reports and presents data from clinical and epidemiologic studies on relationships among oral health status, chronic oral infections (of which caries and periodontitis predominate), and certain systemic diseases, specifically focusing on type 2 diabetes and aspiration pneumonia. Both of these diseases increase in occurrence and impact in older age groups. The NHANES III data demonstrate that dental caries and periodontal diseases occur with substantial frequency and represent a burden of unmet treatment need in older adults. Our review found clinical and epidemiologic evidence to support considering periodontal infection a risk factor for poor glycemic control in type 2 diabetes; however, there is limited representation of older adults in reports of this relationship. For aspiration pneumonia, several lines of evidence support oral health status as an important etiologic factor. Additional clinical studies designed specifically to evaluate the effects of treating periodontal infection on glycemic control and improving oral health status in reducing the risk of aspiration pneumonia are warranted. Although further establishing causal relationships among a set of increasingly more frequently demonstrated associations is indicated, there is evidence to support recommending oral care regimens in protocols for managing type 2 diabetes and preventing aspiration pneumonia.

Cigarette smoking and periodontitis: methodology to assess the strength of evidence in support of a causal association

Identification of the cause of the development and progression of periodontitis has received extensive attention, with notable advances over the past decade in clinical, microbiological, immunological, biochemical, and behavioral knowledge. However, it is still largely unknown which factors lead to the conversion of non-destructive forms of periodontal disease into destructive forms and disease progression. Chronic adult periodontitis is believed to be influenced by an interaction of host defense and environmental factors. Although these variables have been studied extensively, no study has employed randomized controlled prospective human or randomized controlled community intervention designs, methodologies necessary to prove a variable to be a cause of periodontitis. Owing to the absence of literature employing rigorous experimental design, this article assesses systematically observational, cross-sectional and longitudinal studies to examine the potential causal association between cigarette smoking and periodontitis. The methodology of Sir Bradford Hill's criteria for causation was used as the framework. Results suggest that cigarette smoking is causally associated with periodontitis. That is, cigarette smoking is consistently associated with an increased prevalence/severity of periodontitis and is suspected on theoretical grounds of playing a causal role. Hill's criteria provide a useful methodology to better understand the pathogenesis of periodontal diseases and may be applied to study the pathogenesis of other dental diseases as well.

Factors associated with adult periodontitis in a dental teaching clinic population

Exposure to a number of environmental, behavioral and sociodemographic variables has been associated with increased prevalence and severity of adult periodontitis. However, it is not possible easily to identify the individuals most susceptible to this chronic disease. A case control study was conducted among a population of adults to determine what factors were associated with increased prevalence of moderate to advanced periodontitis. Clinical and radiographic data were obtained from dental charts and structured interviews were conducted by telephone to collect sociodemographic and behavioral data. Statistical modeling was completed for the total study population (35-87-year-olds) and for two age-stratified subpopulations. Significant crude disease associations were observed between periodontitis and numerous explanatory variables. However, after adjustment for age and gender, few variables remained significant. Age stratification indicated that young adults (35-54 years) were affected differently from older adults (> or =55 years) by exposures to certain variables. Young moderate smokers had a 3.15 times increased risk of periodontitis and young heavy smokers had a 7.33 times increased risk compared to never-smokers. Older single adults had a 3.07 times increased risk compared to those with partners.

Non-insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years

This study tested the hypothesis that persons with non-insulin dependent diabetes mellitus (NIDDM) have greater risk of more severe alveolar bone loss progression over a 2-year period than those without NIDDM. Data from the longitudinal study of the oral health of residents of the Gila River Indian Community were analyzed for 362 subjects, aged 15 to 57, 338 of whom had less than 25% radiographic bone loss at baseline, and who did not develop NIDDM nor lose any teeth during the 2-year study period. The other 24 subjects had NIDDM at baseline, but met the other selection criteria. Bone scores (scale 0-4) from panoramic radiographs corresponded to bone loss of 0%, 1%-24%, 25%-49%, 50%-74%, or 75% and greater. Change in bone score category was computed as the change in worst bone score (WBS) reading after 2 years. Age, calculus, NIDDM status, time to follow-up examination, and baseline WBS were explanatory variables in regression models for ordinal categorical response variables. NIDDM was positively associated with the probability of a change in bone score when the covariates were controlled. The cumulative odds ratio for NIDDM at each threshold of the ordered response was 4.23 (95% C.I. = 1.80, 9.92). In addition to being associated with the incidence of alveolar bone loss (as demonstrated in previous studies), these results suggest an NIDDM-associated increased rate of alveolar bone loss progression.

Periodontal status of Finnish adolescents with insulin-dependent diabetes mellitus

The periodontal status of 85 12-18 year-old Finnish adolescents with insulin-dependent diabetes mellitus (IDDM) and their paired, age- and sex-matched healthy controls was assessed clinically and radiographically. The clinical examination consisted of plaque index, gingival index (GI), retentive calculus index, WHO community periodontal index of treatment needs, number of pockets greater than or equal to 4 mm and number of surfaces bleeding after probing. Alveolar bone loss was measured interproximally from the first molars in bite-wing radiographs (all subjects) and from the first incisors in periapical X-rays (patients only). The results show that in spite of similar plaque scores, the patients had higher GI scores and more surfaces bleeding after probing. No differences were found in the number of greater than or equal to 4 mm pockets or radiographical bone loss in the first molars.

Detection of high-risk groups and individuals for periodontal diseases. Systemic predisposition and markers of general health

The evidence for systemic predisposition to periodontal diseases is reviewed in relation to cellular and humoral immunity, drug therapy, diet and nutrition and stress. It is concluded that, apart from defects of polymorphonuclear leukocytes (PMN) and Ehlers-Danlos Syndrome, little firm evidence exists for other diseases, though insulin-dependent diabetes and acquired immune deficiency syndrome (AIDS) may accelerate and/or potentiate the damage of existing disease. The precise rôle of drugs, diet and nutrition and stress remain to be elucidated, but recent advances in these areas offer the prospect of assessing risk using carefully controlled studies.

Studies of dental and oral changes of pregnant diabetic women

The longitudinal examination of 132 pregnant diabetic women under care showed a 96.2% prevalence of gingivitis. The intensity of gingivitis was most marked in weeks 11 to 15, and 24 to 26 of pregnancy, and the correlation with changes in oral hygiene was statistically significant (p less than 0.001). On the other hand, the severity of diabetes had no effect on the degree of gingival inflammation. As for caries, the mean DMF values increased during diabetic pregnancy, the number of carious (D) and filled (F) teeth to a higher, that of extracted (M) teeth to a lesser degree, than in diabetic non-pregnant women.

Root surface caries and periodontal disease in long-term alloxan diabetic rats

Caries, periodontal disease, and occlusal wear were studied in rats with short-term (one month) and long-term (12 months) untreated alloxan diabetes and in age-matched control rats. Standard laboratory diet and water were given ad libitum. Streptococcus mutans and lactobacilli were naturally occurring inhabitants of the oral bacterial flora. In short-term diabetic rats, there was less dental plaque in the gingival region of the first mandibular molar than in control rats, but the density of leukocytes in the junctional epithelium was increased. Interdentally, the gingival papillae were intact, and the prevalence of foreign material was as low as for the controls. No caries lesions were seen. The proportion of the oral flora which was lactobacilli was positively correlated with the blood glucose level. In long-term diabetic rats, there was more periodontal breakdown than in the age-matched control rats. The periodontal breakdown was always associated with large interdental impactions of foreign material. Caries was seen only in the diabetic rats and in sites with interdental impactions. The decay was shown to start in the cementum at the cemento-enamel junction. The amount of alveolar bone loss, but not the amount of dental caries, was related to the degree of hyperglycemia. Occlusal wear of the molars in long-term diabetic rats was significantly increased as compared with that in the controls.