Diabetes and Systemic effects

Question 1

What systemic diseases are associated with periodontitis?

Answer 1

Cardiovascular diseases

Diabetes

Adverse pregnancy outcomes

Respiratory diseases

Kidney diseases

Rheumatoid arthritis and other

Autoimmune diseases

Obesity

Cognitive impairments

Alzheimers

Cancer

Question 2

How can periodontitis and peri-implantitis influence systemic conditions?

Answer 2

2 possible pathways:

Direct mechanism: Direct infection by periodontal bacteria through ulcerated pocket epithelium and bloodstream.

Indirect mechanism: Systemic inflammation model. (Inflammatory responses to periodontium have systemic effects)

Question 3

What is the systemic inflammation model?

Answer 3

Blood and tissue cells where these antigens relocate produce inflammatory mediators.

Excessive production of inflammatory mediators in periodontal lesions/sites enter bloodstream and affect distant organs.

Question 4

What cytokines are released into the blodstream from periodontitis?

Answer 4

Increased circulating pro-inflammatory cytokines: IL-1, IL-6, and TNF-a

Decreased circulating anti-inflammatory cytokines: IL-4 and IL-10

Altered blood counts: Leukocytes +, PMN +, Platelets +, Lymphocytes -, and erythrocytes -

Increasing circulating levels of acute phase response: Non-specific systemic markers of inflammation: C-reactive protein and fibrinogen (ESR)

Question 5

What non-specific systemic responses are seen in acute phase response?

Answer 5

Fever

Increase of vascular permeability

Increase of metabolic processes

Question 6

What non-specific inflammation markers increase in levels from periodontitis? What kind of relationship is there?

Answer 6

C-reactive protein: Chronic infections >3 mg/L. This is a dose-response relationship.

Erythrocyte sedimentation markers: Increased fibrinogen production, and increased pro coagulation cascade. no info on dose-response relationship

Question 7

What is diabetes?

Answer 7

High level of blood glucose due to lack of insulin response/presence in the blood.

Question 8

What is the difference between type 1 and type 2 diabetes?

Answer 8

Autoimmune destruction of pancreatic beta cells in type 1 compared to resistance to insulin in type 2

Total loss of insulin production in type 1 compared to reduced insulin production in type 2.

Type 1 is usually diagnosed in children and adolescents whereas type 2 in 40 years or older people and associated with obesity.

Question 9

How common is diabetes?

Answer 9

Over 250 million cases worldwide

Rates have doubled over the past 20 years

Question 10

What are the clinical symptoms of diabetes?

Answer 10

Fatigue

Infections

Vision alteration

Weakness

Hyperglycaemia

Pruritis

Polyphagia

Polyuria

Question 11

What dental conditions are diabetics more prone to getting?

Answer 11

Periodontitis

Periodontal abscess

others

Question 12

What are the diagnostic criteria for diabetes?

Answer 12

HbA1c (%): Diabetes = >=6.5. Prediabetes = 5.7 - 6.4, Normal = ~5.7

Fasting plasma glucose (mg/dL): Diabetes = >=126, prediabetes = 100 - 125, Normal = <=99

Oral glucose test (mg/dL): Diabetes = >=200, pre-diabetes = 140 - 199, normal = <= 139

Question 13

What racial group have the highest prevalence of diabetes?

Answer 13

Pima Indians

Question 14

What is the link between diabetes and periodontitis?

Answer 14

Periodontitis has higher prevalence in diabetics

2.8-3.8x increase in risk for periodontitis in diabetics.

Question 15

How is the severity of periodontitis affected by glycaemic control?

Answer 15

Poorly controlled diabetes has x11 risk for periodontitis compared to non-diabetic

Glycaemic control is related to periodontitis in a dose-dependent manner (level of hyperglycaemia is related to periodontitis)

Diabetics with complications have poorer periodontal health.

Well controlled diabetics have similar risk for periodontitis to non-diabetics

Question 16

What factors influence daibetes’ effect on periodontitis?

Answer 16

Degree of glycaemic control/metabolic control

Age

Duration of DM

Severity of DM - complications

Question 17

Why are diabetics more prone to periodontitis?

Answer 17

Impaired neutrophil function (Impaired adherence, chemotaxis, and phagocytosis) This leads bacteria to persist in periodontal pockets.

AGE protein interaction with RAGE leading monocytes + macrophages to proliferate, upregulate proinflammatory cytokines and produce free O2 radicals. These cytokines and O2 radicals contribute to periodontal disease

Healing is impaired due to decrease in collagen production and increase in MMP production by fibroblasts, decreased osteoblast proliferation and collagen production, and increased rate of apoptosis of fibroblasts and osteoblasts

Question 18

What are AGE proteins?

Answer 18

Structural changes occur in proteins due to irreversible glycation. This results in the formation of AGE proteins. AGEs activate a receptor known as RAGE found on smooth muscle cells, endothelial cells, monocytes/macrophages, and gingival tissues of type 2 diabetics.

Question 19

What happens to healing response in periodontium? Why?

Answer 19

It is compromised due to:

Gingival fibroblasts produce less collagen and more MMPs

Recently synthesized collagen is rapidly degraded by elevated levels of active MMPs

Decreased osteoblast proliferation and collagen production

Increased rate of apoptosis of fibroblasts and osteoblasts

Question 20

How can periodontal disease increase risk of diabetes?

Answer 20

Periodontal infection may add to systemic inflammation and induce insulin resistance

High level of cytokines can affect efficacy of insulin receptor

Question 21

How can periodontal disease increase risk of diabetes?

Answer 21

Periodontal infection may add to systemic inflammation and induce insulin resistance

High level of cytokines can affect efficacy of insulin receptor

Periodontal infection contributes to poorer glycaemic control & increased risk for diabetic complications in diabetics

Question 22

What is the effect of periodontal treatment on diabetics?

Answer 22

Short-term studies suggest healing response in diabetics to be similar to non-diabetics.

Periodontal disease has higher risk of relapse in poorly-controlled diabetes.

Healing response similar in diabetics (well-controlled) compared to non-diabetics

But diabetics may have an increased risk for
post-surgical infection & impaired wound healing

Question 23

What is the influence of periodontal treatment on diabetes?

Answer 23

More studies report significant benefit of periodontal treatment

Improvement in glycaemic control after SRP +/- adjunctive systemic antibiotics of approximately 1% in HbA1c

Question 24

How are HbA1c and diabetes related deaths related?

Answer 24

UK prospective diabetes study showed that every percentage point decrease in HbA1c was associated with 25% reduction in diabetes-related deaths

Question 25

What approach should the dental practitioner take for periodontal management of diabetic patients?

Answer 25

Education of patients and physicians about:

Diabetes can affect periodontal health depending on diabetes control.

Uncontrolled diabetics are at higher risk of periodontal destruction and also present with more severe periodontal disease.

Diabetics have an altered immune response to bacteria and poorer healing response.

Periodontal infections can worsen glycaemic control and increase risk for diabetic complications

Question 26

How effective are dental implants in patients with diabetes?

Answer 26

Emerging evidence that diabetics have more chance to develop biological complications (mucositis and peri-implantitis).

Higher failure rates.

No evidence of contra-indication to implant placement (unless
uncontrolled diabetes)

Glycemic control should be maintained.