Wijnand J. Teeuw

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

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.

Treatment of periodontitis improves the atherosclerotic profile: a systematic review and meta‐analysis

AIM Systematic review and meta-analyses to study the robustness of observations that treatment of periodontitis improves the atherosclerotic profile. MATERIAL AND METHODS Literature was searched in Medline-PubMed, Cochrane CENTRAL and EMBASE, based on controlled periodontal intervention trials, including also a non-intervention group. Data were extracted and meta-analyses were performed. RESULTS From 3928 screened studies, 25 trials met the eligibility criteria. These trials enrolled 1748 periodontitis patients. Seven trials enrolled periodontitis patients that were otherwise healthy, 18 trials recruited periodontal patients with various co-morbidities, such as CVD or diabetes. None of the trials used hard clinical endpoints of CVD. However, improvement of endothelial function has been consistently reported. Meta-analyses demonstrated significant weighted mean difference (WMD) for hsCRP (-0.50 mg/l, 95% CI:-0.78; -0.22), IL-6 (-0.48 ng/l, 95% CI: -0.90; -0.06), TNF-α (-0.75 pg/ml, 95% CI: -1.34; -0.17), fibrinogen (-0.47 g/l, 95% CI: -0.76; -0.17), total cholesterol (-0.11 mmol/l, 95% CI: -0.21; -0.01) and HDL-C (0.04 mmol/l, 95% CI: 0.03; 0.06) favouring periodontal intervention. Importantly, periodontitis patients with co-morbidity benefitted most from periodontal therapy; significant WMD were observed for levels of hsCRP (-0.71 mg/l, 95% CI: -1.05; -0.36), IL-6 (-0.87 ng/l, 95% CI: -0.97; -0.78), triglycerides (-0.24 mmol/l, 95% CI: -0.26; -0.22), total cholesterol (-0.15 mmol/l, 95% CI: -0.29; -0.01), HDL-C (0.05 mmol/l, 95% CI: 0.03; 0.06) and HbA1c (-0.43%, 95% CI: -0.60; -0.25). CONCLUSIONS This systematic review and meta-analyses demonstrate that periodontal treatment improves endothelial function and reduces biomarkers of atherosclerotic disease, especially in those already suffering from CVD and/or diabetes.

Validation of a dental image analyzer tool to measure alveolar bone loss in periodontitis patients

BACKGROUND AND OBJECTIVE Radiographs are an essential adjunct to the clinical examination for periodontal diagnoses. Over the past few years, digital radiographs have become available for use in clinical practice. Therefore, the present study investigated whether measuring alveolar bone loss, using digital radiographs with a newly constructed dental image analyzer tool was comparable to the conventional method, using intra-oral radiographs on film, a light box and a Schei ruler. MATERIAL AND METHODS Alveolar bone loss of the mesial and distal sites of 60 randomly selected teeth from 12 patients with periodontitis was measured using the conventional method, and then using the dental image analyzer tool, by five dentists. The conventional method scored bone loss in categories of 10% increments relative to the total root length, whereas the software dental image analyzer tool calculated bone loss in 0.1% increments relative to the total root length after crucial landmarks were identified. RESULTS Both methods showed a high interobserver reliability for bone loss measurements in nonmolar and molar sites (intraclass correlation coefficient > or = 0.88). Also, a high reliability between both methods was demonstrated (intraclass correlation coefficient nonmolar sites, 0.98; intraclass correlation coefficient molar sites, 0.95). In addition, the new dental image analyzer tool showed a high sensitivity (1.00) and a high specificity (0.91) in selecting teeth with > or = 50% or < 50% alveolar bone loss in comparison with the conventional method. CONCLUSION This study provides evidence that, if digital radiographs are available, the dental image analyzer tool can reliably replace the conventional method for measuring alveolar bone loss in periodontitis patients.

A Lead ANRIL Polymorphism Is Associated with Elevated CRP Levels in Periodontitis: A Pilot Case-Control Study.

Elevated high sensitive C-reactive protein (hsCRP) is a marker for systemic inflammation and a risk marker for atherosclerotic cardiovascular disease (ACVD), and has also been associated with periodontitis. Inter-individual variation for hsCRP in periodontitis has been shown. ANRIL is the strongest genetic susceptibility locus for both periodontitis and ACVD, and it is speculated that genetic variation in ANRIL may modulate inflammatory processes. Therefore, we explored the possible association between hsCRP plasma levels and a leading ANRIL single nucleotide polymorphism (SNP) in periodontitis patients and controls. 171 healthy subjects with North European descent (115 periodontitis and 56 controls) were included in this case-control study. hsCRP levels were determined and subjects were genotyped for the leading ANRIL SNP rs1333048. In a multivariate analysis, periodontitis, female gender, increasing BMI and homozygosity for the major allele (AA-genotype) of rs1333048 were significantly associated with elevated hsCRP plasma levels (p = 0.012, p = 0.004, p = 0.007 and p = 0.003, respectively). Periodontitis patients with rs1333048 AA-genotype showed higher levels of hsCRP than those carrying the minor C allele (median: 4.5 mg/L vs. 1.6 mg/L, padjusted = 0.007). This study is the first to show that, in addition to gender and BMI, also a leading SNP in ANRIL is explanatory for inter-individual variation in hsCRP levels in periodontitis patients of North European descent.

Periodontitis as a possible early sign of diabetes mellitus

Objective The early diagnosis of (pre)diabetes mellitus is essential for the prevention of diabetes complications. It has been suggested that gum disease (periodontitis) might be an early complication of diabetes and may be a useful risk indicator for diabetes screening. Therefore, a dental office could be a good location for screening for (pre)diabetes in patients with periodontitis using a validated glycated hemoglobin (HbA1c) dry spot analysis. Research design and methods A total of 313 individuals from a university dental clinic participated. From 126 patients with mild/moderate periodontitis, 78 patients with severe periodontitis and 109 subjects without periodontitis, HbA1c values were obtained by the analysis of dry blood spots. Differences in mean HbA1c values and the prevalence of (pre)diabetes between the groups were analyzed. Results The mild/moderate and severe periodontitis groups showed significantly higher HbA1c values (6.1%±1.4% (43 mmol/mol±15 mmol/mol) and 6.3%±1.3% (45 mmol/mol±15 mmol/mol), respectively) compared with the control group (5.7%±0.7% (39 mmol/mol±8 mmol/mol), p=0.003). In addition, according to the American Diabetes Association (ADA) guidelines for diagnosis, there was a significant over-representation of subjects with suspected diabetes (23% and 14%) and pre-diabetes (47% and 46%) in the severe periodontitis group and mild/moderate periodontitis groups, respectively, compared with the control group (10% and 37%, p=0.010). Notably, 18.1% of patients with suspected new diabetes were found among subjects with severe periodontitis compared with 9.9% and 8.5% among subjects with mild/moderate periodontitis and controls, respectively (p=0.024). Conclusions The dental office, with particular focus on patients with severe periodontitis, proved to be a suitable location for screening for (pre)diabetes; a considerable number of suspected new diabetes cases were identified. The early diagnosis and treatment of (pre)diabetes help to prevent more severe complications and benefit the treatment of periodontitis.

Arterial stiffness in periodontitis patients and controls: A case-control and pilot intervention study

Increased arterial stiffness (AS) is an important indicator for atherosclerotic cardiovascular disease (ACVD). Epidemiologically, periodontitis and ACVD are associated. Therefore, we aimed to investigate AS in periodontitis patients and controls. In addition, we explored the effect of periodontal therapy on AS in a sub-group of cases. Pulse-wave velocity (PWV), a non-invasive chair-side function test for AS, was measured in periodontitis patients (n=57; mean age 46.6 years) and compared with a reference group (n=48; mean age 45.5 years). In addition, 45 cases (mean age 46.9 years) were 6 months followed after periodontal treatment, to explore a possible effect on arterial function. Periodontitis patients showed a significantly increased PWV compared with the reference group (8.01±0.20 vs 7.36±0.22 m s−1 respectively; P=0.029) and this remained significant after adjustments for ACVD risk factors (P=0.019). After periodontal therapy, no significant reduction in PWV was seen (8.00±1.8 to 7.82±1.6 m s−1; P=0.13), but systolic blood pressure (SBP) was significantly reduced (119.8±14.6 to 116.9±15.1 mm Hg; P=0.040). It can be concluded that periodontitis is associated with increased AS. This confirms with a new parameter the association of periodontitis with ACVD. Although periodontal treatment did not lower AS significantly, a modest reduction of SBP after 6 months was observed.

Oral health information from the dentist to the diabetologist

BACKGROUND Diabetes care includes annual evaluation of micro- and macrovascular complications, however, oral pathologies are not included. We studied retrieving oral health information, in particular periodontal disease, from the dentist and studied the association between the reported periodontal condition and variables of both diabetes and dental care. METHODS During their annual comprehensive diabetes evaluation, patients were asked to deliver an oral health questionnaire (OHQ) to their dentist. Based on the returned OHQs, the process of retrieving oral health information from the dentist was analyzed. In addition, reported oral health measures with special emphasis to periodontitis, using a Periodontal Screening Index (PSI), were related to diabetes-related variables. RESULTS We included 889 patients of whom 102 patients (11%) did not visit a dentist at all and 252 (28%) were edentulous. The response rate was <50% for oral information on patients with diabetes. For the second aim, OHQs of 207 patients could be further analyzed. A moderate to high PSI-score was found in 106 patients, of whom 65% were untreated for periodontitis. Furthermore high PSI-scores were associated with poor oral hygiene, soft tissue pathologies and periodontal treatment, but not significantly with glycemic control and presence of diabetes complications. CONCLUSION The transfer of information from the dentist to the diabetologist is far from optimal. An OHQ can be a valuable tool for the identification of patients with diabetes with poor oral health especially untreated periodontal disease, which is helpful for proper diabetes management.

Plausible mechanisms explaining the association of periodontitis with cardiovascular diseases

The association between periodontitis and cardiovascular diseases is now well established. Cardiovascular diseases include atherosclerosis, coronary heart (artery) disease, cerebrovascular disease, and peripheral artery disease. Atherosclerosis is the underlying pathology of cardiovascular diseases. In this chapter, we describe plausible mechanisms to explain the link between periodontitis, atherosclerosis, and the subsequent cardiovascular diseases. The explanations for the development and exacerbation of atherosclerotic plaques in periodontitis patients include: (1) bacteremia, (2) a pro-inflammatory state, (3) a prothrombotic state, (4) an overactive immunity, (5) dyslipidemia, and (6) common genetic risk factors. Most likely, these plausible mechanisms play all simultaneously a role. Obviously, much more fundamental and clinic research is needed to further study the associations between periodontitis and atherosclerotic diseases.

Effect of periodontal therapy with systemic antimicrobials on parameters of metabolic syndrome: A randomized clinical trial

Abstract Aim To investigate the effect of basic periodontal therapy (BPT) with antimicrobials (AM) on the parameters of metabolic syndrome (MetS) (waist circumference, systolic/diastolic blood pressure [BP], HDL‐cholesterol, triglycerides, glucose). Methods One hundred and ten periodontitis patients without known comorbidities and unaware of possible MetS were randomly assigned to BPT (n = 56) or BPT+AM (n = 54) and followed for 12 months post‐therapy. Number of patients with undiagnosed MetS was also determined. Results In all patients, the periodontal condition improved; however, the BTP+AM group showed greater pocket depth reduction than the BPT group. Post‐therapy, systolic BP (p < .05) and triglycerides (p < .05) reduced significantly during the follow‐up period. No significant differences could be assessed between the BPT+AM and BPT group. Despite the absence of self‐reported comorbidities, 27.2% (n = 30) periodontitis patients fulfilled the criteria of MetS at baseline. After therapy, this proportion changed to 14.5% at 3 months (p = .007), to 17.3% at 6 months (p = .017) and to 21.8% at 12‐month follow‐up (p = .383). Conclusion Although a reduction in systolic BP and triglycerides and a temporarily improvement in the whole metabolic status were observed, the use of antimicrobials in conjunction with BTP does not yield any additional improvement in the parameters of MetS.

De effecten van parodontale behandeling bij parodontitispatiënten met diabetes mellitus type 2

Parodontitis is op twee manieren geassocieerd met andere ziekten: 1) parodontitis kan optreden bij mensen bij wie de weerstand is verlaagd; 2) parodontitis is een mogelijke risicofactor bij een aantal belangrijke en veelvoorkomende ziekten.