Title:

Diabetes and Periodontitis

Names of authors:

Dr. Benazir Ghani Dr. G.S. Srikanth Dr. Preeti Bhattacharya Dr. Manvi Agarwal

Name of presenting author:

Dr. Benazir Ghani (9027115463)

Name of institution and city: Institute Of Dental Sciences, Bareilly

DIABETES AND PERIODONTITIS ABSTRACT

Diabetes mellitus is a systemic disease with several major complications affecting both the quality and length of life. Lifestyle factors related to obesity, eating behavior, and physical activity play a major role in the prevention and treatment of type 2 diabetes. In recent years, there has been progress in the development of behavioral strategies to modify these lifestyle behaviors. Further research, however, is clearly needed, because the rates of obesity in our country are escalating, and changing behavior for the long term has proven to be very difficult. This review article, on behavioral science research in diabetes, identifies four key topics related to obesity and physical activity that should be given high priority in future research efforts: 1) environmental factors related to obesity, eating, and physical activity; 2) adoption and maintenance of healthful eating, physical activity, and weight; 3) etiology of eating and physical activity; and 4) multiple behavior changes One of these complications is periodontal disease (periodontitis). Periodontitis is much more than a localized oral infection. Recent data indicate that periodontitis may cause changes in systemic physiology. The interrelationships between periodontitis and diabetes provide an example of systemic disease predisposing to oral infection, and once that infection is established, the oral infection exacerbates systemic disease. In this case, it may also be possible for the oral infection to predispose to systemic disease.. It may also be possible for chronic periodontitis to induce diabetes.

INTRODUCTION
.Diabetes has emerged as a major health problem in India .According to International Diabetes Federation every fifth diabetic in world would be an Indian by year 2005. Further the Asian Indian phenotype commonly known as thirfty genotype predispose Indian population to risk of developing diabetes. The first 60 years of the 20th century could be
termed the "medical era," in which allopathic medicine emerged as the dominant approach to health care: this was based on mass vaccination and the extensive use of antibiotics and is still the main aproach in many parts of the world. Now, however, the industrialized parts of the world has entered a "post medical" era, in which physical well-being is undermined by certain types of individual behaviors (e.g., smoking), economic factors (e.g., poverty, overeating), and factors influencing the physical environment . The debate on lifestyle and their impact on health is an expression of search for the ways, meeting the new situations. The chronic conditions like cardiovascular disorders, cancer, and periodontal diseases which make up the bulk of morbidity and psychological disorders such as depression are becoming important. The first key to prevent many of these conditions was considered to be a change in the health behavior . The term "lifestyle" is taken to mean a general way of living based on the interplay between living conditions in the wide sense and individual patterns of behavior as determined by sociocultural factors and personal characteristics. The range of behavioral patterns may open limited or may extend by means of environmental factors. The way in which an individual lives may produce behavioral patterns that are either beneficial or detrimental to health. If health is to be improved, actions must be directed at both the individual and environmental factors affecting lifestyle. The concept of a healthy lifestyle being directly related to health was stressed upon by several authors in

the past and they found that people with an active lifestyle had fewer symptoms in teeth and gums than those with inactive ones. So the concept of lifestyle makes it possible to study behavior in a wider sense and it sheds more light on the personal characteristics of an individual. Our results showed a positive correlation between lifestyle and periodontal status. This is in accordance with Rajala who had shown a positive association between dental health behavior and lifestyle variablesPeople with an unhealthy lifestyle have a poor periodontal status because of their aberrant brushing habits and detrimental effects of smoking. According to Revicki, [7] smokers tend to have a more negative lifestyle in general. It means that the association of tobacco with periodontal health was linked not only to poor oral hygiene but also to poor general lifestyle. Studies in the past have shown that females have a better periodontal status and a more positive dental health behavior compared to males. The reasons attributed to this could be esthetics and social pressure on women to look physically attractive thus causing them to lead a healthier lifestyle than men. When the socioeconomic status was compare It is important to appreciate such disorders and

conditions do not initiate periodontitis, but they may predispose ,accelerate or otherwise increase its progression. to the periodontal status, our study showed a positive association between higher
socioeconomic groups and better periodontal status. This is in accordance with Neuman et al who identified a lower occupational status limiting the use of dental services. Dental visiting is still not considered a preventive dental behavior; at present it only depends on treatment needs. Thus people from the lower income group fail to make prophylactic visits to a dentist thus giving them poorer dental health behavior. When education levels were compared to periodontal status, our study showed a positive association between higher education levels and better periodontal status. This is in accordance with Richard et al. who identified education level also a strong indicator of periodontal status. With regard to self-awareness we found better awareness in three groups: in those with a healthy lifestyle, education, and in those of a higher socioeconomic status.

Diabetes mellitus is an extremely important disease from periodontal standpoint .It is a complex metabolic disorder characterized by chronic hyperglycemia,diminished insulin production,impaired insulin action or a combination of both.This results in inability of glucose to be transported from the bloodstream into the tissues,which in turn results in high blood glucose levels and excretion of sugar in urine. There are mainly two types of diabetes mellitus,TypeI and TypeII With several less common secondary types.Type I diabetes mellitus formerly known as insulin dependent diabetes mellitus (IDDM), is caused by a cell mediated auto immune destruction of the insulin producing beta cells of the islets of langerhans in the pancreas,which results in Insulin deficiency. It accounts for 5% to 10% for all cases of diabetes and most often occurs in children and young.
Type II diabetes mellitus formerly known as non insulin dependent diabetes mellitus is caused by peripheral resistance to insulin action,impaired insulin secretion and increased glucose production in liver. This is most common type .Another category of diabetes is gestational diabetes.

Periodontitis is defined as inflammatory disease of supporting tissues of teeth caused by specific microorganism, resulting in progressive destruction of periodontal ligament and alveolar bone with pocket formation ,recession or both. In recent years a lot of emphasis has been laid on

multifactorial aspect of disease entity. Microbiological ,immunological, environmental, genetic and systemic factors ,all contributes in a way or other to the pathogenesis and \progression of periodontal disease. Various systemic diseases have been considered to play a major and crucial role in periodontal destruction by modulating the host side of disease interaction, of which one of the most common condition is diabetes mellitus . Persons with diabetes mellitus (DM) are at greater risk of developing PD. PD is now considered the sixth complication of DM . Not only is it more prevalent in this population, but also the progression of symptoms,in a more aggressive and more rapidly setting mode.The main reasons for this situation are the scarce information on the importance of oral hygiene, poor metabolic control and the irregularity in visiting dentists,among others . PD conditions the loss of dental organs, making chewing food difficult, causing pain and as a result,inadequate nutrition . In addition, frequently persons with DM have a much more difficult time in tolerating false dentures due to total bone loss and the sensitivity of the alveolar mucosa.The participation of a physician is relevant in the opportune detection of PD as a health provider for diabetics and whom a patient comes into more contact with. This article reviews the literature analyzing the bidirectional relationship between diabetes mellitus and periodontal disease, as well as the effects of periodontaltreatment on glycemic control with the aim of providing physicians and health personnel the basic elements supporting this relationship and which contribute to their active participation in the diagnosis and opportune referral.

The precise Etiology of most cases of diabetes is uncertain, although certain contributing factors are as follows:

Type 1 diabetes
Type 1 Diabetes is autoimmune disease that affects 0.3% on average. It is result of destruction of beta cells due to aggressive nature of cells present in the body. Researchers believe that some of the Etiology and Risk factors which may trigger type 1 diabetes may be genetic, poor diet (malnutrition) and environment (virus affecting pancreas). Secondly, in most of the cases, diabetes occurs because there is abnormal secretion of some hormones in blood which act as antagonists to insulin. Example- Adrenocortical hormone, Adrenaline hormone and Thyroid hormone.

Type 2 diabetes
Type 2 Diabetes is also called non insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. It occurs when the body produces enough insulin but cannot utilize it effectively. This type of diabetes usually develops in middle age. A general observation says that about 90-95 % of people suffering with diabetes are type 2; about 80 percent are overweight. It is more common among people who are older; obese; have a family history of diabetes; have had gestational diabetes. There are number of risk factors found to be responsible for type 2 diabetes like, the more the Etiology and Risk factors carried by an individual, the higher the risk for developing diabetes.

Following are the Causes of Diabetes

Hereditary or Inherited Traits : It is strongly believed that due to some genes which passes from one generation to another, a person can inherit diabetes. It depends upon closeness of blood relationship as mother is diabetic, the risk is 2 to 3%, father is diabetic, the risk is more than the previous case and if both the parents are diabetic ,the child has a much greater risk for diabetesAge : Increased age is a factor which gives more possibility than in younger age. This disease may occur at any age, but 80% of cases occur after 50 year, incidences increase with the age factor. Poor Diet (Malnutrition Related Diabetes) : Improper nutrition, low protein and fiber intake, high intake of refined products are the expected reasons for developing diabetes. Obesity and Fat Distribution : Being overweight means increased insulin resistance, that is if body fat is more than 30%, BMI 25+, waist grith 35 inches in women or 40 inches in males. Sedentary Lifestyle : People with sedentary lifestyle are more prone to diabetes, when compared to those who exercise thrice a week, are at low risk of falling prey to diabetes. Stress : Either physical injury or emotional disturbance is frequently blamed as the initial cause of the disease. Any disturbance in Cortiosteroid or ACTH therapy may lead to clinical signs of the disease. Drug Induced: Clozapine (Clozaril), olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel) and ziprasidone (Geodon) are known to induce this lethal disease. Infection : Some of the strephylococci is suppose to be responsible factor for infection in pancreas. Sex : Diabetes is commonly seen in elderly especially males but, strongly in women and those females with multiple pregnancy or suffering from (PCOS) Polycystic Ovarian Syndrome.Hypertension : It had been reported in many studies that there is direct relation between high systolic pressure and diabetes. Serum lipids and lipoproteins : High triglyceride and cholesterol level in the blood is related to high blood sugars, in some cases it has been studied that risk is involved even with low HDL levels in circulating blood

Risk Factors for Diabetes

There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes. All three types of diabetes share the same basic characteristic -- the body's inability either to make or to use insulin. Your body needs insulin, a hormone, to be able to use glucose, which comes from the food you eat, for energy. Without enough insulin, glucose stays in the blood, creating high levels of blood sugar. Over time, this buildup causes damage to your kidneys, heart, nerves, eyes, and other organs.One out of every three people with diabetes is unaware they have this chronic condition. According to the American Diabetes Association, that amounts to about 8 million Americans. Type 2 diabetes, often called non-insulin dependent diabetes, is the most common form of diabetes, affecting 90% - 95% of the 21 million people with diabetes. In this article, you'll learn the basics about type 2 diabetes, including symptoms and causes, as well as type 2 diabetes in children. Risk Factors for Type 1 Diabetes

With type 1 diabetes, which starts in childhood, the pancreas stops producing insulin. Insulin is a hormone your body needs to be able to use the energy -- glucose -- found in food. The primary risk factor for type 1 diabetes is a family history of this lifelong, chronic disease

Genetics and family history. . Diseases of the pancreas. . Infection or illness. .

Risk Factors for Type 2 Diabetes

Type 2 diabetes occurs when the body can't use the insulin that's produced, a condition called insulin resistance. Though it typically starts in adulthood, type 2 diabetes can begin anytime in life. Because of the current epidemic of obesity among U.S. childrentype 2 diabetes is increasingly found in teenagers.Here are the risk factors for developing type 2 diabetes. Obesity or being overweight. Impaired glucose tolerance or impaired fasting glucose. Pre diabetes is a milder form of diabetes that's sometimes called impaired glucose tolerance. It can be diagnosed with a simple blood test. Prediabetes is a major risk factor for developing type 2 diabetes. Insulin resistance. Type 2 diabetes often starts with cells that are resistant to insulin. That means they are unable to take in insulin as it moves glucose from the blood into cells. With insulin resistance, the pancreas has to work overly hard to produce enough insulin so cells can get the energy they need. This involves a complex process that eventually leads to type 2 diabetes Ethnic background. Diabetes occurs more often in Hispanic/Latino Americans, AfricanAmericans, Native Americans, Asian-Americans, Pacific Islanders, and Alaska natives. High blood pressure . Hypertension, or high blood pressure, is a major risk factor for diabetes. High blood pressure is generally defined as 140/90 mm Hg or higher. Low levels of HDL "good" cholesterol and high triglyceride levels also put you at risk.History of gestational diabetes. If you developed diabetes while you were pregnant, you've had what is called gestational diabetes. Having had gestational diabetes puts you at higher risk of developing type 2 diabetes later in life.Sedentary lifestyle. Being inactive -- exercising fewer than three times a week -- makes you more likely to develop diabetes.Family history. Having a family history of diabetes -- a parent or sibling who's been diagnosed with this condition -- increases your risk of developing type 2 diabetes.Polycystic ovary syndrome. Women with polycystic ovary syndrome (PCOS) are at higher risk of type 2 diabetesAge. Some doctors advise anyone over 45 to be screened for diabetes. That's because increasing age puts you at higher risk of developing type 2 diabetes. It's important to remember, though, that people at any age can develop diabetes. If you're over 45 and overweight or if you have symptoms of diabetes, talk to your doctor about a simple screening test. Whatever your risk factors for diabetes may be, there's a lot you can do to delay or prevent diabetes. To manage your risk of diabetes, you should manage your blood pressure keep your weight within or near normal ranges get moderate exercise on most days eat a balanced diet

Diabetes management requires awareness. Know what makes your blood sugar level rise and fall and how to control these day-to-day factors.
Know your numbers. Talk to your doctor about what blood sugar levels are appropriate for you before you begin exercise.Check your blood sugar level. Check your blood sugar level before, during and after exercise, especially if you take insulin or medications that lower blood sugar. Be aware of warning signs of low blood sugar, such as feeling shaky, weak, confused, lightheaded, irritable, anxious, tired or hungry.Stay hydrated. Drink plenty of water while exercising because dehydration can affect blood sugar levels.Be prepared. Always have a small snack or glucose pill with you during exercise in case your blood sugar drops too low. Wear a medical identification bracelet when you're exercising.Adjust your diabetes treatment plan as needed. If you take insulin, you may need to adjust your insulin dose before exercising or wait a few hours to exercise after injecting insulin. Your doctor can advise you on appropriate changes in your medication. You may need to adjust treatment if you've increased your exercise routine. Medication Insulin and other diabetes medications are designed to lower your blood sugar level when diet and exercise alone aren't sufficient for managing diabetes. But the effectiveness of these medications depends on the timing and size of the dose. And any medications you take for conditions other than diabetes can affect your blood sugar level, too. What to do:

Store insulin properly. Insulin that's improperly stored or past its expiration date may not be effective.Report problems to your doctor. If your diabetes medications cause your blood sugar level to drop too low, the dosage or timing may need to be adjusted.Be cautious with new medications. If you're considering an over-the-counter medication or your doctor prescribes a new drug to treat another condition such as high blood pressure or high cholesterol ask your doctor or pharmacist if the medication may affect your blood sugar level. Sometimes an alternate medication may be recommended.

Influence of diabetes on oral health

The impact of diabetes mellitus on the oral cavity has been well researched, and will be reviewed only briefly. A large body of evidence demonstrates

that diabetes is a risk factor for gingivitis and periodontitis The degree of glycemic control is an important variable in the relationship between diabetes and periodontal diseases, with a higher prevalence and severity of gingival inflammation and periodontal destruction being seen in those with poor control . Large epidemiological studies have shown that diabetes increases the risk of alveolar bone loss and attachment loss approximately three-fold when compared to nondiabetic individuals . These findings have been confirmed in meta-analyses of studies in various diabetic populations . In longitudinal analyses,diabetes increases the risk of progressive bone loss and attachment loss over time . The degree of glycemic control is likely to be a major factor in determining risk. For example, in a large epidemiological study in the U.S. (NHANES III), adults with poorly controlled diabetes had a 2.9-fold increased risk of having periodontitis compared to nondiabetic subjects; conversely, subjects with well-controlled diabetes had no significant increase in the risk for periodontitis. Similarly, poorly controlled type 2 diabetic subjects had an 11-fold increase in the risk for alveolar bone loss over a 2-year period compared to nondiabetic control subjects . On the other hand, well-controlled type 2 patients had no significant increase in risk for longitudinal bone loss compared to nondiabetic controls. Many of the mechanisms by which diabetes influences the periodontium are similar to the pathophysiology of the classic microvascular. Many of the mechanisms by which diabetes influences the periodontium are similar to the pathophysiology of the classic microvascular and macrovascular diabetic complications. There are few differences in the subgingival microbiota between diabetic and nondiabetic patients with periodontitis . This suggests that alterations in the host immunoinflammatory response to potential pathogens may play a predominant role. Diabetes may result in impairment of neutrophil adherence, chemotaxis,and phagocytosis, which may facilitate bacterial persistence in the periodontal pocket and significantly increase periodontal destruction . While neutrophils are often hypofunctional in diabetes, these patients may have a hyper-responsive monocyte/macrophage phenotype, resulting in significantly increased production of pro-inflammatory cytokines and mediators . This hyperinflammatory response results in elevated levels of pro-inflammatory cytokines in the gingival crevice fluid. Gingival crevice fluid is a serum transudate, thus, elevated serum levels of inflammatory mediators may be reflected in similarly elevated levels of these mediators in gingival crevice fluid. The level of cytokines in the gingival crevice fluid has been related to the level of glycemic control in diabetic patients. In one study of diabetic subjects with periodontitis, those with hemoglobin A1c levels >8% had gingival crevice fluid levels of interleukin-1b almost twice as high as subjects whose hemoglobin A1c levels were <8% . The net effect of these host defense alterations in diabetes is an increase in periodontal inflammation, attachment loss, and bone loss. Elevated pro-inflammatory cytokines in the periodontal environment may play a role in the increased periodontal destruction seen in many people with diabetes.Formation of advanced glycation end-products, a critical link in many diabetic complications, also occurs in the periodontium, and their deleterious effects on other organ systems may be reflected in periodontal tissues as well . Likewise, a 50% increase in messenger RNA for the receptor of advanced glycation end-products was recently identified in the gingival tissues of type 2 diabetic subjects compared to nondiabetic controls . Matrix metalloproteinases are critical components of tissue homeostasis and wound healing, and are produced by all of the major cell types in the periodontium. Production of matrix metalloproteinases such as collagenase increases in many diabetic patients, resulting in altered collagen homeostasis and wound healing within the periodontium

Influence of periodontal infection on diabetes

Periodontal diseases are inflammatory in nature; as such, they may alter glycemic control in similar manner to obesity, another inflammatory condition.Studies have shown that diabetic patients with periodontal infection have a greater risk of worsening glycemic control over time compared to diabetic subjects without periodontitis . Because cardiovascular diseases are so widely prevalent in people with diabetes, and because studies suggest that periodontal disease may be a significant risk factor for myocardial infarction and stroke, a recent longitudinal ltrial examined the effect of periodontal disease on mortality from multiple causes in over 600 subjects with type 2 diabetes . In subjects with severe periodontitis, the death rate from ischemic heart disease was 2.3 times higher than the rate in subjects with no periodontitis or only slight disease, after accounting for other known risk factors. The death rate from diabetic nephropathy was 8.5times higher in those with severe periodontitis. The overall mortality rate from cardio-renal disease was 3.5-fold higher in subjects with severe periodontitis, suggesting that the presence of periodontal disease poses a risk for cardiovascular and renal mortality in people with diabetes. Periodontal intervention trials suggest a significant potential metabolic benefit of periodontal therapy in people with diabetes. Several studies of diabetic subjects with periodontitis have shown improvements in glycemic control following scaling and root planning combined with adjunctive systemic doxycycline therapy . The magnitude of change is often about 0.91.0% in the hemoglobin A1c test. There are some studies in which periodontal treatment was associated with improved periodontal health, but minimal impact was seen on glycemic control.Most of these studies used scaling and root planning alone, without adjunctive antibiotic therapy. Conversely,a recent study of well controlled type 2 diabetic patients who had only gingivitis or mild, localized periodontitis examined the effects of scaling and localized root planing without systemic antibiotics. A diabetic control group with a similar level of periodontal disease received no treatment. Following therapy, the treated subjects had a 50% reduction in the prevalence of gingival bleeding and a reduction in mean hemoglobin A1c from 7.3%to 6.5%. The control group, which received no periodontal treatment, had no change in gingival bleeding, as expected, and no improvement in hemoglobin A1c. These results suggest that changes in the level of gingival inflammation after periodontal treatment may be reflected by changes in glycemic control. Several mechanisms may explain the impact of periodontal infection on glycemic control. As discussed above, systemic inflammation plays a major role in insulin sensitivity and glucose dynamics.Evidence suggests that periodontal diseases can induce or perpetuate an elevated systemic chronic inflammatory state, as reflected in increased serum C-reactive protein, interleukin-6, and fibrinogen levels seen in many people with periodontitis .Inflammation induces insulin resistance, and such resistance often accompanies systemic infections. Acute nonperiodontal bacterial and viral infections have been shown to increase insulin resistance and aggravate glycemic control . Periodontal infection may similarly elevate the systemic inflammatory state and exacerbate insulin resistance.Tumor necrosis factor-a, produced in abundance by adipocytes, increases insulin resistance by preventing autophosphorylation of the insulin receptor and inhibiting second messenger signaling via inhibition of the enzyme tyrosine kinase . Interleukin-6 is important in stimulating tumor necrosis factor-a production; thus

elevated interleukin-6 production in obesity results in higher circulating levels of both interleukin-6 and tumor necrosis factor-a. Periodontal infection can induce elevated serum interleukin-6 and tumor necrosis factor-a levels, and may play a similar role as obesity in inducing or exacerbating insulin resistance.

Effect of Periodontal Treatment on the State of Diabetes

Periodontal treatment decreases local inflammation and as a consequence, decreases chemical mediators involved in inflammation, among them IL-6 and CRP,positively contributing to proper glycemic control. It is evident that PD exceeds the local environment affecting the systemic one .D'Auito points out that tissue insulin demand in type I diabetic patients decreases after periodontal treatment including scraping and radicular smoothing,curettage, local gingivectomies and selective extractions, scaling and root planning in addition to the use of antibiotics such as penicillin and streptomycin.The most important concern for applying evidence in the early diagnosis of PD is educating the patient. Periodontal disease is a silent condition. Diabetics need to be aware of the signs of PD (Table 1). Bleeding of the gums is the first sign of subgingival infection.This is when all the personnel involved in the care of diabetic patients should take active participation and therefore opportunely refer patients to the dentist. . Signs of Alarm related to Periodontal Disease Gum bleeding Gingival inflammation Halitosis Sensitive denture Dental movement

Conclusions
Diabetic patients are commonly encountered in the dental office. Proper patient management requires close interaction between the dentist and physician.Dentists and other oral health care providers should understand the diagnostic and therapeutic methodologies used in diabetes care. They must be comfortable with the parameters of glycemia that are used to establish a diagnosis and an assessment of patients_ ongoing glycemic control. A thorough understanding of the pharmacological agents commonly encountered in this patient population is a must. The dentist should know how these agents can affect the risk for hypoglycemia, and should be able to manage such events should they occur in the office.Dentists must educate patients and their physicians about the interrelationships between periodontal health and glycemic control, with an emphasis on the inflammatory nature of periodontal diseases and the potential systemic effects of periodontal infection. Working with diabetic patients can be challenging and rewarding when open lines of communication are established and thorough patient education is attained.

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