Diabetes and Systemic effects Flashcards
What systemic diseases are associated with periodontitis?
Cardiovascular diseases
Diabetes
Adverse pregnancy outcomes
Respiratory diseases
Kidney diseases
Rheumatoid arthritis and other
Autoimmune diseases
Obesity
Cognitive impairments
Alzheimers
Cancer
How can periodontitis and peri-implantitis influence systemic conditions?
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)
What is the systemic inflammation model?
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.
What cytokines are released into the blodstream from periodontitis?
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)
What non-specific systemic responses are seen in acute phase response?
Fever
Increase of vascular permeability
Increase of metabolic processes
What non-specific inflammation markers increase in levels from periodontitis? What kind of relationship is there?
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
What is diabetes?
High level of blood glucose due to lack of insulin response/presence in the blood.
What is the difference between type 1 and type 2 diabetes?
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.
How common is diabetes?
Over 250 million cases worldwide
Rates have doubled over the past 20 years
What are the clinical symptoms of diabetes?
Fatigue
Infections
Vision alteration
Weakness
Hyperglycaemia
Pruritis
Polyphagia
Polyuria
What dental conditions are diabetics more prone to getting?
Periodontitis
Periodontal abscess
others
What are the diagnostic criteria for diabetes?
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
What racial group have the highest prevalence of diabetes?
Pima Indians
What is the link between diabetes and periodontitis?
Periodontitis has higher prevalence in diabetics
2.8-3.8x increase in risk for periodontitis in diabetics.
How is the severity of periodontitis affected by glycaemic control?
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
What factors influence daibetes’ effect on periodontitis?
Degree of glycaemic control/metabolic control
Age
Duration of DM
Severity of DM - complications
Why are diabetics more prone to periodontitis?
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
What are AGE proteins?
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.
What happens to healing response in periodontium? Why?
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
How can periodontal disease increase risk of diabetes?
Periodontal infection may add to systemic inflammation and induce insulin resistance
High level of cytokines can affect efficacy of insulin receptor
How can periodontal disease increase risk of diabetes?
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
What is the effect of periodontal treatment on diabetics?
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
What is the influence of periodontal treatment on diabetes?
More studies report significant benefit of periodontal treatment
Improvement in glycaemic control after SRP +/- adjunctive systemic antibiotics of approximately 1% in HbA1c
How are HbA1c and diabetes related deaths related?
UK prospective diabetes study showed that every percentage point decrease in HbA1c was associated with 25% reduction in diabetes-related deaths
What approach should the dental practitioner take for periodontal management of diabetic patients?
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
How effective are dental implants in patients with diabetes?
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.
