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

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

Chronic diseases are accelerating globally, advancing across all regions and pervading all socioeconomic classes. Unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress are the most important risk factors. Periodontal disease is a component of the global burden of chronic disease, and chronic disease and periodontal disease have the same essential risk factors. In addition, severe periodontal disease is related to poor oral hygiene and to poor general health (e.g. the presence of diabetes mellitus and other systemic diseases). The present report highlights the global burden of periodontal disease: the ultimate burden of periodontal disease (tooth loss), as well as signs of periodontal disease, are described from World Health Organization (WHO) epidemiological data. High prevalence rates of complete tooth loss are found in upper middle-income countries, whereas the tooth-loss rates, at the time of writing, are modest for low-income countries. In high-income countries somewhat lower rates for edentulism are found when compared with upper middle-income countries. Around the world, social inequality in tooth loss is profound within countries. The Community Periodontal Index was introduced by the WHO in 1987 for countries to produce periodontal health profiles and to assist countries in the planning and evaluation of intervention programs. Globally, gingival bleeding is the most prevalent sign of disease, whereas the presence of deep periodontal pockets (≥6 mm) varies from 10% to 15% in adult populations. Intercountry and intracountry variations are found in the prevalence of periodontal disease, and these variations relate to socio-environmental conditions, behavioral risk factors, general health status of people (e.g. diabetes and HIV status) and oral health systems. National public health initiatives for the control and prevention of periodontal disease should include oral health promotion and integrated disease-prevention strategies based on common risk-factor approaches. Capacity building of oral health systems must consider the establishment of a financially fair service in periodontal care. Health systems research is needed for the evaluation of population-oriented oral health programs.

The global burden of periodontal disease: towards integration with chronic disease prevention and control.

OBJECTIVE There is growing evidence that periodontitis may affect general health. This study was assigned to explore the robustness of observations that periodontal therapy leads to the improvement of glycemic control in diabetic patients. RESEARCH DESIGN AND METHODS A literature search (until March 2009) was carried out using two databases (MEDLINE and the Cochrane Library) with language restriction to English. Selection of publications was based on 1 ) original investigations, 2 ) controlled periodontal intervention studies where the diabetic control group received no periodontal treatment, and 3 ) study duration of ≥3 months. RESULTS Screening of the initial 639 identified studies and reference checking resulted in five suitable articles. A total of 371 patients were included in this analysis with periodontitis as predictor and the actual absolute change in A1C (ΔA1C) as the outcome. The duration of follow-up was 3–9 months. All studies described a research population of type 2 diabetic patients in whom glycemic control improved after periodontal therapy compared with the control group (range ΔA1C: Δ−1.17 up to Δ−0.05%). The studies in a meta-analysis demonstrated a weighted mean difference of ΔA1C before and after therapy of −0.40% (95% CI −0.77 to −0.04%, P = 0.03) favoring periodontal intervention in type 2 diabetic patients. Nevertheless, this improvement in %A1C must be interpreted with care due to limited robustness as evidenced by heterogeneity among studies (59.5%, P = 0.04). CONCLUSIONS The present meta-analysis suggests that periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients for at least 3 months.

https://care.diabetesjournals.org/content/diacare/33/2/421.full.pdf

Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients A systematic review and meta-analysis

OBJECTIVE: This report reviews the evidence for adverse effects of diabetes on periodontal health and periodontal disease on glycemic control and complications of diabetes. DESIGN: MEDLINE search of the English language literature identified primary research reports published on (a) relationships between diabetes and periodontal diseases since 2000 and (b) effects of periodontal infection on glycemic control and diabetes complications since 1960. RESULTS: Observational studies provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal disease in 13/17 reports reviewed. Treatment and longitudinal observational studies provided evidence to support periodontal infection having an adverse effect on glycemic control, although not all investigations reported an improvement in glycemic control after periodontal treatment. Additionally, evidence from three observational studies supported periodontal disease increasing the risk for diabetes complications and no published reports refuted the findings. CONCLUSION: The evidence reviewed supports diabetes having an adverse effect on periodontal health and periodontal infection having an adverse effect on glycemic control and incidence of diabetes complications. Further rigorous study is necessary to establish unequivocally that treating periodontal infections can contribute to glycemic control management and to the reduction of the burden of diabetes complications. Oral Diseases (2008) 14, 191–203

SPECIAL REVIEW IN PERIODONTAL MEDICINE Periodontal disease: associations with diabetes, glycemic control and complications

Background: Obesity is increasing in prevalence and is a major contributor to worldwide morbidity. One consequence of obesity might be an increased risk for periodontal disease, although periodontal inflammation might, in turn, exacerbate the metabolic syndrome, of which obesity is one component. This review aims to systematically compile the evidence of an obesity–periodontal disease relationship from epidemiologic studies and to derive a quantitative summary of the association between these disease states. Methods: Systematic searches of the MEDLINE, SCOPUS, BIOSIS, LILACS, Cochrane Library, and Brazilian Bibliography of Dentistry databases were conducted with the results and characteristics of relevant studies abstracted to standardized forms. A meta-analysis was performed to obtain a summary measure of association. Results: The electronic search identified 554 unique citations, and 70 studies met a priori inclusion criteria, representing 57 independent populations. Nearly all studies matching inclusion criteria were cross-sectional in design with the results of 41 studies suggesting a positive association. The fixed-effects summary odds ratio was 1.35 (Shore-corrected 95% confidence interval: 1.23 to 1.47), with some evidence of a stronger association found among younger adults, women, and non-smokers. Additional summary estimates suggested a greater mean clinical attachment loss among obese individuals, a higher mean body mass index (BMI) among periodontal patients, and a trend of increasing odds of prevalent periodontal disease with increasing BMI. Although these results are highly unlikely to be chance findings, unmeasured confounding had a credible but unknown influence on these estimates. Conclusions: This positive association was consistent and coherent with a biologically plausible role for obesity in the development of periodontal disease. However, with few quality longitudinal studies, there is an inability to distinguish the temporal ordering of events, thus limiting the evidence that obesity is a risk factor for periodontal disease or that periodontitis might increase the risk of weight gain. In clinical practice, a higher prevalence of periodontal disease should be expected among obese adults. J Periodontol 2010;81:1708-1724.

Association Between Chronic Periodontal Disease and Obesity: A Systematic Review and Meta-Analysis

Opinions on the interdependence between diabetes mellitus and oral periodontal disease are controversial. Experimental and clinical investigations carried out so far have not brought unique results. General objective of our research is to investigate on the strictly defined group of subjects aged 35-44 with diabetes mellitus type I the influence of metabolic control HbA1C on changes of periodontium and other organs. According to duration of diabetes mellitus the patients are divided into subdecade and postdecade groups. This group consists of 56 patients out of which 33 patients are with subdecade and 23 with postdecade insulin-dependent diabetes mellitus. In this group periodontal pocket depths, gingival index, number of extracted teeth and the volume of nonstimulated saliva are measured in comparison with a control group. The incidence of oral diseases and complications in other organs of insulin-dependent patients in subdecade and postdecade period are also examined and recorded. Periodontal diabetic disease is verified by pathohistological findings. Values of HbA1C in either subdecade or postdecade group with diabetes mellitus are above normal values. Values of periodontal pocket depths as well as the values of gingival index are substantially greater at insulin-dependent diabetes mellitus patients compared to the control group.

Diabetes mellitus and periodontal diseases

According to Salomon, diabetes mellitus is a chronic disease caused by inadequate insulin action. As a syndrome, it could come in practice in many different forms. This disease, from genetic aspect presents a very heterogeneous phenomenon. For that reason a research of oral cavity tissue in diabetic patients presents a very complex problem from the scientific point of view. Truly, in the research today there are controversial cognition about relationship between diabetes mellitus and oral cavity diseases: diabetic stomatopathy, oral candidiasis, alterations of oral mucosa and periodontia. In this paper a special aspect is given to the research of incidence of candidiasis which is the result of contamination of all other pathological alterations in oral cavity.

Diabetes mellitus and Candida albicans

Psychoactive drug misuse, as bad habit, is local ethiologic factor of periodontal diseases, and it represents the significant socio-medical problem. The aim of study is: to establish the values of plaque and gingival index in psychoactive drug addicts. The study has been carried out in 42 patients. Experimental group consists of psychoactive drug addicts, and control group consists of patients who have not used psychoactive drugs. The plaque and gingival index show significant difference between experimental and control group. Psychoactive drug misuse has the influence to increased adherence of dental plaque and gingival inflammation, and therapeutic approach is at multidisciplinary level.

Periodontal findings in patients addicted to psychoactive drugs

Objective: Youngsters like to experiment with risky life stiles, without adequate knowledge about long-term health effects. Bosnia and Herzegovina is currently going through transition period and is a postwar society with various risk factors for drugs abuse (economic, social and health). The main objective of the research was to describe adolescents behavior in consumption of alcohol and in relation to area type, gender, religion, age, parental attitude, friends and to investigate effect of biological hereditary factors related to certain behavior. Methods: This epidemiological research was done in urban and rural areas of Sarajevo Canton, involving 368 adolescents: 170 males, 198 females; aged 12-17, with equal urban and rural distribution. The research tool used was Q 2004 (K.B. Kelly, 2000). Using this tool, impact of hereditary factors related to tobacco, alcohol and drugs was explored and EPI info was used for statistical analysis. Results: Out of total number of individuals involved in the study 25.8% were found to be cigarette smokers, 39.4% consumed alcohol, and 2.2% consumed marijuana. Out of total number of adolescents who use alcohol, 43.4% are from rural and 56.6% urban area; 69.0% come from high school and 31% from primary; 53.1% are male; 46.9% female; 44.8% alcohol consumers smoke tobacco vs. 13.5%; 4.8% use drugs and alcohol vs. 0.4%. Mean age of alcohol consumption beginning was 14. Results determine genealogical analysis of frequency of consuming alcohol and tobacco related paternal side (maternal side rarely) and adolescent. It is not proved that hereditary factors play important role in use of these substances. Impact of hereditary factors among drug users is negative. Conclusion: Adolescents in developing countries tend to abuse psychoactive substances. It is determined that parents (particularly father) use tobacco and alcohol, but rarely. None of above mentioned family members abuse drugs. Therefore, impact of hereditary factors related to abuse drugs is not proved. These results could be used to develop an appropriate prevention strategy. It is necessary to be aware of all relevant risk factors. Quality of life depends of these factors, and treatment should be multidisciplinary for these cases, including medical, genetic and dental experts in the field.

Dedić A

Papers

Diabetes mellitus and periodontal diseases

Diabetes mellitus and Candida albicans

Periodontal findings in patients addicted to psychoactive drugs

Impact of Hereditary Factors on Adolescents' Behavior Related to Tobacco, Alcohol and Drugs Use in Bosnia and Herzegovina