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Diabetes & Periodontal Health:
A Two-way relationship.
Francesco D’AiutoDMD, MClinDent, PhD, MRD RCS(Eng) RCPS (Glasg)
HEFCE Senior Clinical Lecturer/ Hon Consultant Periodontology Unit
Endothelial damage,
platelet aggregation
HSP 60,
molecular mimicry
Oral Cavity – Systemic Exposure
Periodontitis
Questions:
• Does Diabetes Mellitus affects Periodontal Health?
• Does Periodontal Health affects Diabetes Mellitus and its complications?
• Does periodontitis treatment improves metabolic control in people with Diabetes?
I. Type 1 diabetes* - previously known asjuvenile diabetes insulin-dependent diabetes
mellitus (IDDM)II. Type 2 diabetes* - previously known as
adult-onset diabetes non-insulin-dependent diabetes mellitus (NIDDM)
III. Other specific types (includes Secondary Diabetes)
IV. Gestational diabetes mellitus (GDM)American Diabetes Association: http://care.diabetesjournals.org/
IDF Atlas 2006
46.5
80.3
73%
67.0
99.4
48%10.4
18.7
80%
24.5
44.5
81%
53.2
64.1
21%28.3
40.5
43%
16.2
32.7
102%
World
2007 = 246 million
2025 = 380 million
Increase 55%Diabetes Atlas, 3rd edition, IDF 2006
Weyer C, et al. J Clin Invest. 1999;104:787-794.
Insulin resistance
Hyperinsulinemia
Compensated insulin resistanceNormal glucose tolerance
Impaired glucose tolerance
ß-cell “failure”
Type 2 diabetes
Genetic Factors
Genetic Factors
Acquired:•Obesity
•Sedentary lifestyle•Aging
ß-cell decompensation
Glucose and/or fat toxicity
DCCT Research Group.. 1993;329:977
EVERY 1% reduction in HbA1C
REDUCED RISK*
1%
Deaths from diabetes
Heart attacks
Microvascular complications
Peripheral vascular disorders
*p<0.0001Stratton IM, et al 2000
DIABETES
Periodontal Diseases- Gingivitis- Periodontitis
Oral Lichen Planus
Caries
Xerostomia
Candidiasis
• Case/Control (N=350/group)
Lalla et al 2006
From Cianciola et al JADA1982
• Experimental Gingivitis (N=9/arm)
Salvi et al 2005
From G. Taylor 1996
From Graves et al Periodontol 2000 2007
Type 2 Diabetes
Hypertension
DyslipidemiaCentral obesityInsulinResistance
TG
GlucoseDiabetes
BP
HDL
AbdominalObesity
Apo BLittle LDL PAI-1
Adipo-nectin
InsulinResistance
CRP
Microalb
Cardio- vascularDisease
Type 2Diabetes
Metabolic syndrome
• 28 Zucker rats diabetes – Ligature induced periodontitis (P) versus control (C).
• High (HF) vs Low (LF) Fat Diet
Watanabe et al 2008
Variable% or mean (95%CI)
Mild or no Periodontitis
(N=11758)
Moderate Periodontitis
(N=1582)
Severe Periodontitis
(N=337)
D’Aiuto F et al 2008
Nibali Let al 2013
• NHANES I Follow-up study (7,168 dentate) • 47% had periodontal index 0 (periodontally healthy); the
remaining periodontal index quintiles.
Demmer et al 2008
Collin et al 1998
Prospective study
Prospective study (2y) Pima Indians
Reviewed in Taylor 2008
• N=628 (>35 y) periodontal disease on CV mortality in Pima Indians with type 2 diabetes
• 11 years FU
Saremi et al 2005
• 529 individuals, – 107 (20%) none/mild – 200 (38%) moderate – 117 (22%) severe – 105 (20%) edentulous
• Up to 22 years FU
Shultis et al 2007
Janket et al 2005
Teeuw et al 2010
Updated search to 2009
Engrebretson & Kocher 2013
Variable Control (N=49) Test (N=43) P value
Age 58.48±1.64 60.02±1.69 0.515Male Gender, N (%) 34 (77,3) 28(57,1) 0.049Smoking N (%):CurrentFormerNever
13 (29,5)12 (27,3)20 (40,8)
13 (26,5) 19 (43,2) 16 (32,7)
0.369
BMI 27.31±0.55 27.50±0.79 0.853Diabetes age, years 16.50±0.90 18.04±1.67 0.558HbA1c, % 8.03±0.22 7.64±0.16 0.166SES N (%):LowMediumHigh
21 (47,7)17 (38,6)6 (13,6)
34 (69,4)13 (26,5)
2 (4,1)
0.069
Calabrese N, D’Aiuto F et al 2011
Baseline 4 Months 8 Months
HbA
1c %
0,0
7,2
7,5
7,8
8,1
8,4
TestCTRL
*=1.08%
95% CI 1.01 to 1.14, P=0.026
Calabrese N, D’Aiuto F et al 2011
Variable Control (N=10) Test (N=10)Age, years 54.99±6.67 55.44±6.64Male Gender, N (%) 6 (60) 8(80)Smoking N (%):NeverCurrent
7 (70)3 (30)
8 (80) 2(20)
BMI, Kg/m2 28±2 26±1
HbA1c, % 8.30±0.16 8.13±0.19
CRP, mg\L 4.31±0.64 3.19±1.13
WBC, 109 cell 6.24±0.61 5.42±0.40
D’Aiuto F et al Unpublished
D’Aiuto F et al Unpublished
=0.64%95%CI 0.18 to 1.26, P=0.044
D’Aiuto F et al 2005
202124 202124N =
IPTSPTControl
CRP
[mg/
L]
8
6
4
2
0
BL
2M202124 202124N =
IPTSPTControl
IL-6
[pg/
ml]
5
4
3
2
1
0
BL
2M
Periodontal Therapy - Chronic Inflammation
Correa et al 2010
• 23 T2-DM before and 3 months after non-surgical periodontal therapy.
Baseline Day 1 Day 7 1 Month 2 Months 6 Months
FM
D %
0
1
4
5
6
7
8
9
10
IPT (N=61)
CPT (N=59)
=2.0%95% CI 1.2 to 2.8,
P<0.0001
Tonetti MS, D’Aiuto F et al 2007
Periodontal Therapy - Endothelial Function
Experimental Design - RCT (N=250) UKCRN 5280
SCR
EEN
ING
BASELINE
Randomization
2m 12m1d 7d 9m6m
Test
Control
At October 2013: • N=285 recruited• N=250 reached 6 months fw-up• N=237 reached 12 months fw-up
Future goals
• Large epidemiological studies to ascertain the impact of periodontal health/diseases on diabetes incidence and complications.
• Large RCTs on Metabolic/Vascular effects of Treatment of Oral inflammation in people with Diabetes
• Mechanistic studies to clarify the pathways involved • Oral health promotion becoming part of medical
management of people with diabetes
AcknowledgementsProf John E DeanfieldDr Stefano MasiMrs Bhowruth, DevinaDr Marco OrlandiFrancis O’NeillMohamed Parkar
Eastman Clinical Investigation Centre Staff Mrs Jean SuvanNurses (Banbai Hirani, Kasia Niziolek, Tiffany Mellor) Dental hygienists (Alastair Lomax, Chiara Curra’)Heather FinchProf Nikos DonosDr Nikolaos Gkranias
Prof Aroon D Hingorani, UCLProf Liam Smeeth, LSHTMProf Raymond MacAllister, UCLProf Derek Yellon, UCLDr Derek Housenloy, UCLProf Steve E Humphries, UCLDr George Tsakos, UCL
Research Group Collaborators - UK
Collaborators - EUProf Pirkko Pussinen, HelsinkiProf Ulf Landmesser, Zurich
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