Steven P. Engebretson

The effect of nonsurgical periodontal therapy on hemoglobin a1c levels in persons with type 2 diabetes and chronic periodontitis a randomized clinical trial

IMPORTANCEnChronic periodontitis, a destructive inflammatory disorder of the supporting structures of the teeth, is prevalent in patients with diabetes. Limited evidence suggests that periodontal therapy may improve glycemic control.nnnOBJECTIVEnTo determine if nonsurgical periodontal treatment reduces levels of glycated hemoglobin (HbA1c) in persons with type 2 diabetes and moderate to advanced chronic periodontitis.nnnDESIGN, SETTING, AND PARTICIPANTSnThe Diabetes and Periodontal Therapy Trial (DPTT), a 6-month, single-masked, multicenter, randomized clinical trial. Participants had type 2 diabetes, were taking stable doses of medications, had HbA1c levels between 7% and less than 9%, and untreated chronic periodontitis. Five hundred fourteen participants were enrolled between November 2009 and March 2012 from diabetes and dental clinics and communities affiliated with 5 academic medical centers.nnnINTERVENTIONSnThe treatment group (nu2009=u2009257) received scaling and root planing plus chlorhexidine oral rinse at baseline and supportive periodontal therapy at 3 and 6 months. The control group (nu2009=u2009257) received no treatment for 6 months.nnnMAIN OUTCOMES AND MEASURESnDifference in change in HbA1c level from baseline between groups at 6 months. Secondary outcomes included changes in probing pocket depths, clinical attachment loss, bleeding on probing, gingival index, fasting glucose level, and Homeostasis Model Assessment (HOMA2) score.nnnRESULTSnEnrollment was stopped early because of futility. At 6 months, mean HbA1c levels in the periodontal therapy group increased 0.17% (SD, 1.0), compared with 0.11% (SD, 1.0) in the control group, with no significant difference between groups based on a linear regression model adjusting for clinical site (mean difference, -0.05% [95% CI, -0.23% to 0.12%]; Pu2009=u2009.55). Periodontal measures improved in the treatment group compared with the control group at 6 months, with adjusted between-group differences of 0.28 mm (95% CI, 0.18 to 0.37) for probing depth, 0.25 mm (95% CI, 0.14 to 0.36) for clinical attachment loss, 13.1% (95% CI, 8.1% to 18.1%) for bleeding on probing, and 0.27 (95% CI, 0.17 to 0.37) for gingival index (Pu2009<u2009.001 for all).nnnCONCLUSIONS AND RELEVANCEnNonsurgical periodontal therapy did not improve glycemic control in patients with type 2 diabetes and moderate to advanced chronic periodontitis. These findings do not support the use of nonsurgical periodontal treatment in patients with diabetes for the purpose of lowering levels of HbA1c.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00997178.

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

CONTEXTnThe effect of periodontal therapy on diabetes outcomes has not been established.nnnOBJECTIVEnThis update examines the effect of periodontal treatment on diabetes outcomes.nnnDATA SOURCESnLiterature since October 2009 using MEDLINE.nnnSTUDY ELIGIBILITY CRITERIAnPublished RCTs including periodontal therapy for diabetic subjects, a metabolic outcome, an untreated control group, and follow-up of 3 months.nnnDATA EXTRACTIONnPre-defined data fields, including study quality indicators were used.nnnDATA SYNTHESISnA search revealed 56 publications of which 9 met inclusion criteria. Mean change of HbA1c from baseline was compared across treatment groups. Pooled analysis was based on random effects models.nnnRESULTSnA meta-analysis indicated a mean treatment effect of -0.36% HbA1c (CI -0.54, -0.19) compared to no treatment after periodontal therapy (p < 0.0001). Heterogeneity tests revealed only minimal evidence of publication bias (I(2 ) = 9%).nnnLIMITATIONSnSmall sample size and high risk of bias remain problematic for studies of this type. Periodontal therapy varied considerably.nnnCONCLUSIONnThe modest reduction in HbA1c observed as a result of periodontal therapy in subjects with type 2 diabetes is consistent with previous systematic reviews. Despite this finding, there is limited confidence in the conclusion due to a lack of multi-centre trials of sufficient sample size are lacking.

Current Status of Periodontal Risk Assessment

Chronic periodontitis is a destructive chronic inflammatory disease of bacterial etiology. Mounting evidence confirms that not all patients are susceptible to inflammatory periodontal disease, and further, that the extent and severity of its clinical manifestation varies as a function of individual risk. Risk assessment models are needed to target treatment effectively. Contemporary risk assessment, as applied to periodontal disease, represents an innovative approach to managing periodontitis. The central intent of this paper is to review the current view of risk assessment as it relates to the diagnosis and management of chronic periodontitis, as well as to consider a number of such applications that can be incorporated into daily practice.

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

BACKGROUNDnType 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.nnnMETHODSnThe 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.nnnRESULTSnMore 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).nnnCONCLUSIONSnIn 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.

Systemic Inflammatory Biomarkers and Their Association With Periodontal and Diabetes-Related Factors in the Diabetes and Periodontal Therapy Trial, A Randomized Controlled Trial

BACKGROUNDnThe present study evaluates effects of non-surgical periodontal treatment on serum biomarkers in patients with type 2 diabetes mellitus (t2DM) and chronic periodontitis who participated in the Diabetes and Periodontal Therapy Trial (DPTT); and associations among diabetes markers, serum biomarkers, and periodontal measures in these patients.nnnMETHODSnDPTT participants randomized to receive immediate or delayed non-surgical periodontal therapy were evaluated at baseline and 6 months. Serum samples from 475 participants with 6-month data were analyzed for the following biomarkers: 1) high sensitivity C-reactive protein; 2) E-selectin; 3) tumor necrosis factor (TNF)-α; 4) vascular cell adhesion molecule (VCAM); 5) interleukin (IL)-6; 6) IL-8; 7) intercellular adhesion molecule; and 8) IL-10. Changes in biomarker levels from baseline and correlations among biomarker levels and clinical findings were analyzed.nnnRESULTSnNo differences between treatment and control groups were observed for any biomarkers at baseline or 6 months (P >0.05 for all variables). VCAM levels increased by an average (standard deviation) of 17.9 (99.5); ng/mL (P = 0.006) and E-selectin decreased by 2.33 (16.08) ng/mL (P = 0.03) in the treatment group after 6 months. E-selectin levels were significantly correlated with DM-related variables (hemoglobin A1c [HbA1c] and fasting glucose) at baseline and with 6-month change in both groups; no significant correlations were found among periodontal clinical parameters and serum biomarkers or DM-related variables. Neither HbA1c or body mass index varied during the study period in either study group.nnnCONCLUSIONSnNon-surgical periodontal therapy and periodontal disease severity were not associated with significant changes in serum biomarkers in DPTT participants during the 6-month follow-up. Correlations among changes in E-selectin, IL-6, and DM-related variables suggest that t2DM may be the primary driver of systemic inflammation in these patients.

Hemoglobin A1c Levels Among Patients With Diabetes Receiving Nonsurgical Periodontal Treatment—Reply

Author Contributions: Dr Marin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Marin, Yealy, Mannix. Acquisition, analysis, or interpretation of data: Marin, Weaver, Mannix. Drafting of the manuscript: Marin, Yealy, Mannix. Critical revision of the manuscript for important intellectual content: Marin, Weaver, Yealy, Mannix. Statistical analysis: Marin, Weaver, Mannix. Obtained funding: Marin. Administrative, technical, or material support: Marin, Yealy. Study supervision: Marin, Yealy, Mannix.

Effect of patient age awareness on diagnostic agreement of chronic or aggressive periodontitis between clinicians; a pilot study

BackgroundThe aim of this pilot study was to test whether diagnostic agreement of aggressive and chronic periodontitis amongst Board Certified Periodontists, is influenced by knowledge of a patient’s age. In 1999 at the International World Workshop age was removed as a diagnostic criteria for aggressive periodontitis. The impact of this change on the diagnostic reliability amongst clinicians has not yet been assessed.MethodsNine periodontal case reports were twice presented to sixteen board certified periodontists, once with age withheld and again with patient age provided. Participants were instructed to choose a diagnosis of Chronic Periodontitis or Aggressive Periodontitis. Diagnostic agreement was calculated using the Fleiss Kappa test.ResultsIncluding the patients’ age in case report information increased diagnostic agreement (the kappa statistic) from 0.49 (moderate agreement) to 0.61 (substantial agreement).ConclusionThese results suggest that knowledge of a patients’ age influenced clinical diagnosis, when distinguishing between aggressive periodontitis and chronic periodontitis, which may in turn impact treatment decision-making.

Microradiography and microcomputed tomography comparative analysis in human bone cores harvested after maxillary sinus augmentation: a pilot study

OBJECTIVESnThe aim of this study was to compare microradiography (MR) and microcomputed tomography (μCT) analysis of bone samples following maxillary sinus augmentation at different time periods and determine the relationships between measured area and volume fractions.nnnMATERIALS AND METHODSnLateral window sinus grafts were performed on 10 patients using a mineralized human bone allograft (MHBA). At implant placement, 5-13 months after surgery, 10 bone core biopsies were harvested. Prior to histologic sectioning, bone samples were evaluated with μCT. The morphometric parameters computed by MR and μCT were compared using Pearsons correlation and Bland and Altman analysis and included hard tissue fraction (HV/TV:%), soft tissue fraction (SV/TV:%), vital bone fraction (BV/TV:%) and residual graft fraction (GV/TV:%).nnnRESULTSnStrong positive correlation between MR and μCT was found for HV/TV and SV/TV and BV/TV [r = 0.84, 0.84 and 0.69, respectively] but weak for GV/TV [r = 0.10].nnnCONCLUSIONnμCT technology shows promising potential as an indicator of bone morphology changes; however, caution should be used in interpreting morphometric parameters, as the different methods reveal important biases.

Changes in diabetes medications in the Diabetes and Periodontal Therapy Trial and their effect on hemoglobin A1c (HbA1c)

OBJECTIVEnEvaluate the effect of medications and medication changes during the Diabetes and Periodontal Therapy Trial (DPTT) on the primary study outcome, namely, change in hemoglobin A1c (HbA1c) at 6months following baseline.nnnMETHODSnThe DPTT set strict criteria for changes in diabetes medications. Medication change was defined as: change in dose of any 1 oral hypoglycemic agent by more than two-fold, change in dose of insulin of >10% and/or addition or subtraction of an oral hypoglycemic agent, insulin or non-insulin injectable agents. Comparisons between the treatment (non- surgical periodontal therapy) and control (no therapy) groups used t-tests for continuous variables and chi-square tests for categorical variables, including DPTT defined diabetes medication changes between baseline (BL) and 3month visits and 3- and 6-month visits. Changes in HbA1c were compared across the four medication change categories using ANOVA models, overall and for each treatment group separately.nnnRESULTSnBaseline medication use was similar between the treatment groups (p>0.40), as were medication changes between BL- 3month visits and 3 and 6month visits (p=0.58). Participants with higher BL HbA1c (>8%) and those taking insulin at BL were more likely to have a change in medication (p=0.03).nnnCONCLUSIONSnThe DPTT had the most rigorous definition of medication changes and medication monitoring of any trial in this field to date. The absence of a significant difference in medication changes between treatment groups may suggest that such changes did not play a role in the negative outcome of the DPTT.

A novel three-dimensional analysis of standardized bone defects by means of confocal scanner and micro-computed tomography

ObjectivesThe aim of the study was to introduce a novel three-dimensional (3D) method to quantify the relative amount of different tissue components in bone substitute-treated defects by means of integration of confocal laser imaging into micro-computed tomography (μCT) analysis.Materials and methodsOne standardized semisaddle intraosseous defect was prepared in the mandibles of six minipigs and scanned by an optical scanner to capture the surface of the fresh defect in a 3D manner. Subsequently, all the defects were filled with a biphasic calcium phosphate material. The animals were divided into two groups of three animals each, which were allowed to heal for 3 and 8xa0weeks, respectively. μCT analysis followed the two healing periods and was performed on all defect locations. The data from optical scanning and μCT were used for three-dimensional evaluation of bone formation, nonmineralized tissue ratio, and graft degradation. The integration of confocal laser scanning into μCT analysis through a superimposition imaging procedure was conducted using the software Amira (Mercury Computer Systems, Chelmsford, MA, USA).ResultsThe feasibility of combining the confocal imaging into μCT data with regard to obtaining accurate 3D quantification was demonstrated. The amount of tissue components was identified and quantified in all the investigated samples. Quantitative analysis demonstrated that a significant increase in the amount of bone filling the defect was observed in vivo (pu2009<u20090.02) while a significant decrease in the amount of nonmineralized tissue occurred (pu2009<u20090.04). No difference in the amount of residual grafting material was detected between 3 and 8xa0weeks in vivo (pu2009>u20090.38).ConclusionsThe combination of confocal imaging and micro-computed tomography techniques allows for analysis of different tissue types over time in vivo. This method has revealed to be a feasible alternative to current bone regeneration quantification methods.Clinical relevanceAssessment of bone formation in a large animal model is a key step in assessing the performance of new bone substitute materials. Reliable and accurate methods are needed for the analysis of the regenerative potential of new materials.